Wellsville Trout Derby Entry Form

ENTRY FORM
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Registration: (one applicant per form)   If postmarked before April 1st $15; Begining April 1st $20
                                           PLEASE PRINT NEATLY

Last Name _________________________________ First Name ____________________ MI _____

Address _____________________________ City _____________________   St ____   Zip ________

Phone # (          ) _________________________      # BBQ Tickets ________   @ $7.00 _________

Community Fish:   # Tickets ___________ @ $1 Each ______________

I hereby release the Wellsville Lions Club Charities Inc., the Wellsville Area Chamber of Commerce, Inc., and all participating
sponsors of the Derby from any loss of property, bodily injury, or loss of life that may occur in this Derby. I also agree to fish
on the Genesee River only during the contest hours on the dates of this Derby. I have read the rules carefully and agree
to them.

Entrant's Signature _____________________________________________     Date: ____________

Checks payable to: Greater Wellsville Trout Derby
Mail to: Wellsville Area Chamber of Commerce, 114 N. Main St., Wellsville, NY 14895
________________________________________________________________________________________________

( official use only ) Total Received $ __________________   Badge No. _________