Pinellas County Gator Club

3rd Annual
ORANGE & BLUE TARPON TOURNAMENT
June 27th, 2015 Pinellas County, Florida
*Net Proceeds to Emerson Scholarship Program*
ENTRY APPLICATION
*EACH PARTICIPANT MUST FILL OUT AN INDIVIDUAL APPLICATION*
(Including Social Participants)
BOAT NAME*
BOAT OWNER / CHARTER CAPTAIN
NAME*
ADDRESS*
CITY, STATE, ZIP*
CELL NUMBER

EMAIL*

* INDICATES REQUIRED INFORMATION

ALL PARTICIPANTS OF THE TOURNAMENT ENTER AT THEIR OWN RISK.
OFFICIALS, COMMITTEE MEMBERS AND ALL PERSONS CONNECTED DIRECTLY OR INDIRECTLY WITH
THE OPERATION OF THE PINELLAS COUNTY GATOR CLUB ORANGE AND BLUE TARPON DERBY SHALL
BE EXEMPT FROM ANY LIABILITY FOR LOSS, DAMAGE, NEGLIGENCE, HARM OR INJURY SUFFERED TO
ANY PARTICIPANT, ENTRANT, VESSEL, COMPANION, CREW MEMBERS AND EQUIPMENT WHICH MAY
OCCUR DURING THE TOURNAMENT.
I UNDERSTAND AND AGREE WITH THE ABOVE PARAGRAPH. I ALSO UNDERSTAND THE RULES OF THE
PINELLAS COUNTY GATOR CLUB ORANGE AND BLUE TARPON TOURNAMENT AND AGREE TO ABIDE BY
THEM AND ANY DECISION OF THE RULES COMMITTEE. IF ENTRANT IS UNDER 18 YEARS OLD, LEGAL
GUARDIAN OF ENTRANT MUST SIGN THIS FORM.

ENTRANT
(OR LEGAL GUARDIAN):
DATE

Please check only one

prior to Friday June 12th

(maximum of 4 people per boat)

DIVISION

FEE

MEMBER BOAT *
NON MEMBER BOAT
CHARTER BOAT**
SATURDAY SOCIAL
TICKET ONLY

$175
$195
$1050
$10

Rates

Please circle one

Male or Female

Number of
Anglers on Boat

or

1 2 3 4

*Member entry is good for current or new members of the UFAA, Old Salt Fishing Foundation or Reel
Darlins
**Charter boats are subject to availability. Please contact Sean Tobe at 727-644-8638 for availability

Make checks payable to: PINELLAS COUNTY GATOR CLUB

***Mail entry form and check to: 30031 US Highway 19 N, Clearwater, FL 33761***
**** ENTRY FEES INCLUDE COST OF BANQUET AWARDS DINNER FOR THE ELIGIBLE ANGLERS****
No portion of your payment is eligible for a charitable contribution deduction

OFFICIAL USE ONLY

CASH
CHECK

$
CHECK #

AMOUNT

RELEASE, WAIVER, AND INDEMNIFICATION

I, __________________________, in consideration of being permitted to participate in the

Orange & Blue Tarpon Tournament offered by The Pinellas County Gator Club, RELEASE, WAIVE,
DISCHARGE AND COVENANT NOT TO SUE the University of Florida Foundation, Inc., the
University of Florida, the University of Florida Board of Trustees, Board of Education of the State of
Florida, and their respective current or former officers, servants, agents, or employees (individually and
collectively, Released Parties), with regard to any and all liability, claims, demands, actions, and causes
of action, or related to any loss, damage, or injury, including death, that may be sustained or incurred by
me, or to any property belonging to me, during or as a result of my participation in the Event or any
activities in connection with the Event, whether caused by the negligence of any of the Released Parties
or otherwise.
I agree to indemnify the Released Parties from any loss, liability, damage or cost the Released
Parties may incur due to my presence in or at the Event, whether caused by the negligence of the
Released Parties or otherwise.
I assume full responsibility for and risk of bodily injury, death, or property damage due to the
negligence of the Released Parties or otherwise while in or at the Event or while competing, officiating
in, working, or for any other purpose participating in the Event. I further release the Released Parties
from any claim whatsoever on account of first aid treatment or service rendered to me during
participation in the Event.
I expressly agree that this Release, Waiver, and Indemnification (Release) is intended to be as
broad and inclusive as permitted by the laws of the State of Florida and that if any portion of the
agreement is held invalid, the balance will continue in full legal force and effect.
IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT:
1. I have read the foregoing Release and understand its significance. I am signing the Release
voluntarily as my own free act and deed.
2.

I am at least 18 years of age and fully competent (or a parent or guardian signing for a

minor).
I execute this Release for full, adequate, and complete consideration, fully intending this
Release to be binding on myself, my spouse, my family, and my heirs, assigns, and personal
representatives.
3.

________________________________
Witness
Print Witness Name above

_____________________________________
Signature of Participant (or Parent/Guardian)