Fishing Derby Registration

Parent Guardian Information

Parent/Guardian*

First Last

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

Enter Email Confirm Email

Child One

Please fill in all information for each child.

Name*

First Last

Sex*

Male
Female

Age*

Child Two

Name

First Last

Sex

Male
Female

Age

Child Three

Name

First Last

Sex

Male
Female

Age

Photo Release

On behalf of my children, I do hereby give the Chesapeake Bay Environmental Center (CBEC) and its representatives the right to use my picture or photograph in all forms of media for advertising, trade, or any other lawful purpose. I waive the right to inspect and approve the finished product that may be created, to include, but not limited to, written copy, and/or image in print or on a website. I understand that the CBEC cannot control the unauthorized use by other persons once my image is published. Any claim I may have concerning unauthorized publication of my image must be pursued by me against the unauthorized user. CBEC disclaims any responsibility for such unauthorized use of my published image.

I have read and understand the Photo Release statement above.*

I agree to the above statement
I decline permission for my children to be photographed in any form of media by CBEC

How Did You Hear About This Event?

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Phone

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