Junior Anglers Registration - West Texas Rehab

The event will take place on April 26th at Lake Ft. Phantom, located at 10818 FM 600, Abilene, TX. Registration will begin at 8:00 AM, with fishing starting at 9:00 AM. Lunch and an awards ceremony will follow.
Parent/Caregiver, please fill out the registration form. One caregiver and the participant will be allowed to go on a boat with a boater. Anyone in the family is welcome to fish from the shore.

Childs Name

First

Last

Childs Age

Does Child use a wheelchair or powerchair?

Childs T-shirt size?

My child has permission to get on a boat under supervision with a life preserver.

Comment

Caregiver Information

One caregiver and the participant will be allowed to go on a boat with a boater. Anyone in the family is welcome to come and fish from the shore.

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

and all Information

Caregiver T-shirt size?

Total number of family members attending lunch:

Informed Consent and Acknowledgement and Media Release

You must check yes to participate in this event.

I hereby give my approval for my child’s participation in any and all activities prepared by West Texas Rehab Center during this event. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless West Texas Rehab Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against West Texas Rehab Center, including all affiliates, all participants and, if applicable, owners and lessors of premises used to conduct the event.

I hereby grant to West Texas Rehabilitation Center, their agents, successors, assignees, and affiliates, and their respective employees, officers, directors, board members, and representatives (collectively “Producers”) the right and permission to film, photograph, and record me, transcribe the recording, and to use my name, voice, image, information about me and any ideas or materials that I provide Producers (collectively, the “Materials”) in works created by Producers (the “Program”) and in connection with advertising, publicizing, broadcasting, producing, and exploiting the Program, in any and all media and mediums now known hereafter developed, in perpetuity. I understand that Producers are under no obligation to incorporate my appearance in the Program. Producer may edit and Video as it sees fit, and may resnlate the Material into languages other than English.

Signature

Clear Signature