2025 National Lake Trout Derby Registration Form
Please complete the form below to provide details about your submission.
Full Name
*
First Name
Last Name
E-mail
*
Phone
*
Age as of May 23rd 2025
*
Please Select
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Gender
*
Male
Female
Divisional Category
Male - Age 20-59
Female - Age 20-59
Senior (Male or Female) Age 60+
Teen (Male or Female) Age 16 - 19
Juvenile (Male or Female) Age 5 -15
Address
Street Address
Street Address Line 2
City
State
Zip Code
Registration Number
Choose Registration
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Adult Registration
$
50.00
Juvenile Registration
$
15.00
1 Raffle Ticket for $2
$
2.00
Quantity
1
2
3
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9
10
3 Raffle Tickets for $5
$
5.00
Quantity
1
2
3
4
5
6
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8
9
10
13 Raffle Tickets for $20
$
20.00
Quantity
1
2
3
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5
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9
10
Register
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