Bass`n for Better Health Tournament ENTRY FORM

Angler #2
NAME:————————————————————
PARTNER: ——————————————————
ADDRESS: ____________________________________
Your 2015 Sponsorship of the
Foundation made it possible for
us to purchase 3 new EKG
machines and a portable ultrasound for use in the ER and in
surgery. THANK YOU!!
CELL PHONE: ________________________________
E-MAIL: ______________________________________
EMERGENCY CONTACT:
NAME:_________________________________________
RELATIONSHIP: _______________________________
PHONE NUMBER: ______________________________
I have read the Rules and Release of
Liability and Indemnity Agreement
(on opposite page).
_________________________________________________
SIGNATURE
Mail forms to:
Becky Bodkin
423-775-8580
[email protected]
9400 Rhea County Hwy
Dayton, TN 37321
________________________________
DATE
If I am under 18 my parent/guardian
has signed here __________________
and I will be in a boat piloted by
________________________________
The mission of the Rhea Medical
Healthcare Foundation is to
provide support necessary to
enhance Rhea Medical Center’s
mission to partner with its
physicians and the community to
provide safe, quality,
compassionate and affordable
healthcare services.
Bass’n for Better
Health
Tournament
Saturday, June 18, 2016
Dayton Boat Dock
175 Lakeshore Street, Dayton, TN
ENTRY FORM
Traditional Format
With FIVE Cash Prizes:
$2500 1st Place Prize
$1000 2nd Place Prize
$750 3rd Place Prize
$500 Fourth Place Prize
$250 5th Place Prize
2016 Bass’n for Better Health Tournament
Angler #1
NAME:————————————————————
PARTNER: ——————————————————
ADDRESS: ____________________________________
CELL PHONE: ________________________________
E-MAIL: ______________________________________
EMERGENCY CONTACT:
NAME:_________________________________________
RELATIONSHIP: _______________________________
PHONE NUMBER: ______________________________
I have read the Rules and Release of
Liability and Indemnity Agreement.
_________________________________________________
SIGNATURE
________________________________
DATE
If I am under 18 my parent/guardian
has signed here __________________
and I will be in a boat piloted by
________________________________
Liability and Indemnity
Agreement
I understand Bass’n For Better Health is sponsored by Rhea
Medical Healthcare Foundation, a nonprofit organization and my
participation in this tournament is voluntary. Participation in this
event involves the risk of injury, even death from various causes,
including but not limited to accidents, falls, drowning, physical
overexertion, dehydration, illness, collisions with other participants,
weather related injuries, equipment malfunctions, and the negligence
of other participants. On behalf of my family, my heirs and myself I
assume these risks.
Entry Fees
$50 per person
$10 per Person Big Bass Pot
(optional) 50% payback
Prizes
$2500 1st Place
$1000 2nd Place
$750 3rd Place
$500 4th Place
$250 5th Place
In consideration of my participation in Bass’n for Better Health I
hereby release, discharge, hold harmless and indemnify and
covenant to not sue the staff, volunteers, insurers, agents and
representatives of the Rhea Medical Healthcare Foundation nor all
other persons associated with the organization and management of
Bass’n for Better Health , including and without limitation any
other participating sponsors, parents, vendors, event workers, officials, drivers and organizations as to an and all claims by me, my
family, and my heirs for personal injuries suffered by me, property
damage, medical expenses, and economic loss arising directly or
indirectly from my participation in the tournament, and any first aid,
medical care or treatment provided to me in the event I am injured
or become ill while participating in the tournament.
CONTACT US….
I covenant that I have liability insurance for the use of my boat and
fishing equipment providing coverage in an amount not less than
$100,000 for personal injuries and property damages.
IN S UP POR T OF
Should any provision of this Release be deemed invalid, the
remaining provisions will remain in full force and effect. This
Release of Liability and Indemnity Agreement shall be binding
upon me, my family, heirs, next of kin, legal representatives,
beneficiaries, successors and assigns. I give permission for free use
of my name and picture in event photos, broadcasts, telecasts or
written accounts for any participation in Bass’n for Better Health.
R HEA MEDICA L
HEALTHCAR E
FOUN DATI ON
R HEA MEDICA L C ENTER
9400 RHEA COUNTY HWY
DAYTON, TN 37321
423-775-8580
[email protected]