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Registration Form: Please Print


Name: _______________________________________________________________  


Youth Division:    Yes   or    No    (Circle One)




City: __________________________________ State:__________  Zip:___________


Phone: ___________________________         Email:_____________________________


Signed: __________________________________________ Date:_______________      

 (Parent signature required for youth division)


Mail registration to:  SLRWA Ice Derby, 33 Mahoney Rd, Winthrop NY 13697


Liability: Neither the tournament Committee, sponsors, Judges, officers, directors, or employees of the same are responsible for the safety of persons or property in regards to accidents, theft, damage by fire, vandalism, drowning, or any other cause. By signing the entry and release you certify that you expressly understand and agree to hold harmless members of the aforementioned groups and individuals from any liability of claim from damage incurred as a result of participating in the tournament in what ever form or manner said liabilities or damages might be incurred.  I understand that by signing this form I am fishing at my own risk.



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