2009 PARTICIPANT REGISTRATION APPLICATION
Phoenix Event, Oct. 24th & 25TH, 2009, at Lake Pleasant Scorpion Bay

Event Free for: PVA members, Disabled Participants, allowed one free attendant/guest, volunteers. Donations appreciated from all others. Boat space limited, Disabled anglers get first choice
*Support AZPVA by giving a copy of this registration form to one of your friends who might enjoy it, and encouraging them to attend. 

NAME:             

ADDRESS:     

CITY:               

  STATE:               ZIP Code:        

PHONE:            AGE   WEIGHT   SEX  SELECT_ONE FEMALE MALE

E-Mail:          

Emergency contact day of event: 

Exact Disability:     

*Wheelchair:           SELECT_ONE YES NO     *TYPE OF CHAIR SELECT_ONE Electric Manual           Wheelchair needed on boat? Select_One YES NO

Medications (Include all prescription meds.):  

Medical or Special needs (include allergies, need for adaptive fishing device): 

Type of boat you prefer to fish from:   SELECT_ONE Fishing from Boat Fishing from Pontoon Boat

NAME OF ATTENDANT/GUEST:      

Donations from Able Bodied Veterans (Optional): Amount: $10.00 :   $20.00 :   $40.00 :   $50.00

ENTRY AND RELEASE OF ALL CLAIMS:  In consideration of the acceptance of my entry in the "ARIZONA PVA FISHING EVENT" on Oct 24TH & 25TH, 2009, I release, AZ Game & Fish, Lake Pleasant Scorpion Bay Marina, the city of Peoria, Morristown, Maricopa County, all respective agents and employees of the aforementioned and all volunteers connected with this event, from any liability or claims for any injury to body or property or illness that I sustain during my participation in this event.  I understand that this release applies to me, my personal attendants, heirs and assigns.  I represent that I am capable of participating in this event, recognize that risks of injury that may accompany such participation and acknowledge that this release is being relied upon by the above persons in permitting me to participate.  I grant full permission to any and all of the foregoing to use any photographs, videotapes, movies, recordings or any other records of this event for any legitimate purpose.

SIGNATURE _______________________________________ DATE _____________
                       Participant or legal guardian MUST sign this entry.

 AZ Chapter, PVA  8126 N 23rd Ave. Suite J, Phoenix, AZ 85021  602-244-9168
www.azpva.org.