MISSISSIPPI WALLEYE CLUB MEMBERSHIP FORM

Name (Print):______________________________________________________

Address: __________________________________________________________

Address (2): _______________________________________________________

City: _____________________________________________________________

State: ____________________________________________________________

Zip Code: _________________________________________________________

Phone: _____________________________ Cell: _________________________

SELECT ONE

Single ------------------ For $30.00

Family ------------------ For $35.00

WAIVER

I understand that events sponsored by The Mississippi Walleye Club may include potentially dangerous activity. I know and understand all risks associated with participation in events and activities sponsored by The Mississippi Walleye Club, including but not limited to personal injury, effects of weather, and damage to equipment. I understand that I should not participate in activities sponsored by The Mississippi Walleye Club if I am not medically or otherwise capable. I agree to abide by any decision of The Mississippi Walleye Club regarding my fitness or ability to participate in an activity sponsored by the Club.

Having read this waiver, knowing these facts, and in consideration of acceptance of my membership form or participation in any sponsored event, I, for myself and anyone entitled to act on my behalf, waive and release The Mississippi Walleye Club, its directors, officers, members, property owners, boat owners, boat operators or sponsors, assisting or participating in any and all Tournaments or Expos and their representatives and successors, from any and all rights, claims, demands and actions of any and every nature whatsoever that I may have, for any and all loss, damage, or injuries sustained by me.

PLEASE SIGN BELOW

NAME: _________________________________________ DATE: _____________

PARENT/GUARDIAN SIGNATURE IF UNDER 18 ___________

Mail To: Mississippi Walleye Club, P.O. Box 748, Dubuque IA 52004