Participant registration form

Participant registration

Participant Registration is $60 per person ($70 after August 1). This includes all meals, fishing equipment, and liability insurance. Payment should be mailed to : FDL Fishing Has No Boundaries, PO Box 54, Fond du Lac, WI 54936. Please indicate participants name in the subject line on check. Thank you!

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Shirt size *

Email *

Phone Number *

Nature of disability *

Are you in a wheelchair? *

No Yes, a manual wheelchair Yes, a motorized wheelchair Can you be taken out of the chair (check box if yes)?

If you have allergies, please list them here. *

Please list medications. *

Do you need a member of FHNB to administer your medication? *

Yes No

Do you need a personal assistant? *

Yes No

If you need a personal assistant, are you bringing your own? *

Yes No

If you're bringing your own assistant, what is his/her name? *

In some cases, family members like to join the participant for meals. Each meal is $10. Please indicate below which meals will have additional guests. *

Entry or release of all claim: In consideration of the acceptance of my entry in the “Fishing has no boundaries” fishing event, I release FHNB, the City of Fond du Lac, Found du Lac County, sponsors, all respective agents and employers of the aforementioned and all volunteers who are 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 attendant, heirs and assigns. I represent that I am capable of participation and acknowledge that this release is being relied upon by the above persons in permitting me to participate. I also grant full permission to any or all foregoing to use any photographs, videotapes, motion pictures, recordings or any other records of this event for any legitimate purposes. *

Checking this box below will serve as your electronic signature. Clicking this box means you have filled out this form to the best off your ability and have read and agree to the disclaimer. *

Yes, I agree to the above and understand checking this box constituents my electronic signature.

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