New Minor Release Form

WESTERN PA TEAM BASS SERIES MINOR RELEASE FORM

Please fill out the annual membership form and return with this minor release form. No individual under the age of 16 years of age shall fish in the B.A.S.S. Team Championship. No individual under 18 years of age shall fish by themselves in any Western PA Team Bass Series event.

First Name

Last Name

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

DATE OF BIRTH

SSN#

Phone

Team Members Name

*This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided by the annual membership form release as well as all releases on this page, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the releases from any and all liabilities incident to my minor child's involvement or participation in any event held by Western PA Team Bass Series as provided by the annual membership form and this form, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES, to the fullest extent permitted by law.

*(By typing your name, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By typing your name, you consent to be legally bound by this Agreement’s terms and conditions. You further agree that your use of a key pad, mouse, or other device to type your name. You also agree that no certification authority of other third-party verification is necessary to validate your E-Signature and that the lack of such certifications or third-party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and WPTBS. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement)

Signature of Minor

Select a date

Signature of Parent/Guardian

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Thanks for registering!