(Please print!)

Name: ______________________________________

Address: __________________________________________

City: _____________________State.________ZIP___________

Phone: (include area code) Daytime (____) _____________________

Nights (____) ___________________

E-mail: ________________________

___Yes, I have access to the web.

___No, I do not have access to the web.

___Yes include my address and phone number on the team roster.

___No, do not include my address and phone number on the team roster.

WAIVER: In consideration of your acceptance of my application, I for myself, my heirs, my executors and my administrators, hereby release and hold harmless and forever discharge the Virginia Catfish Association, their servants, agents, representatives, successors, assignees, hosts, sponsors, event officials, other event participants and the Virginia Department of Game and Inland Fisheries from any and all claims for personal injury, death, dismemberment, or property damage which I may experience during the course of the events for the entire year of 2008. I also agree to abide by the event rules and Virginia State Laws, including all Virginia Boating Regulations for the duration of all events for the year 2008.

Signature: _______________________________________________ Date: _________________