Fishing Derby Registration 2021 Parent Guardian InformationParent/Guardian* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneEmail* Enter Email Confirm Email Child OnePlease fill in all information for each child.Name* First Last Sex* Male Female Age* Child TwoName First Last Sex Male Female Age Child ThreeName 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? Facebook Email Print Media Other NameThis field is for validation purposes and should be left unchanged.