Registration Form

Blanchardville Police Department

Cops & Bobbers Registration
PARTICIPANT INFORMATION
PARENT/GUARDIAN INFORMATION

First NameLast Name
Phone NumberFormat: (000) 000-0000.
Email
Address

Street Address

CityState

Zip Code
Will your child need a fishing pole?
Informed Consent and Acknowledgement

I, the parent(s) or guardian(s) of the above-named participant, hereby give my/our approval to this child’s participation in the Cops and Bobbers Event. I assume all risks and hazards incidental to such participation, and I hereby waive, release, absolve, indemnify, and agree to hold harmless releasees for any claim arising or of an injury to my/our child and from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever arising out of or connected with my/our child’s participation in the Fishing Event and the Property Owner. I consent to the foregoing and grant permission for my/our child to participate in the Fishing Derby. I acknowledge I have carefully read, accept, and agree to the terms on this Release, and know and understand their contents and I sign the same on my/our own free act and deed. I attest that if my/our child, the above-named participant, is under 18 years of age years of age as of the date of the Fishing Derby, he or she will be accompanied by an adult eighteen years of age or older throughout his or her participation in the Fishing Derby.
Media Release

Blanchardville Police Department and its authorized representatives may photograph, videotape, record, and/or otherwise capture images, likeness, voice, and participation during the Cops & Bobbers event. These photographs, videos, recordings, and related materials may be used for lawful purposes including, but not limited to: Department newsletters and publications, Social media platforms, Department websites, Local newspapers and media outlets, Community presentations and promotional materials, public information and educational purposes. No compensation will be provided for the use of these materials. Once images or recordings are published, the Blanchardville Police Department cannot control their subsequent use by third parties.
Type a question
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

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Signature
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Blanchardville Police Department

Media Release