Disabled Veteran Registration Form

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Registration for the 2016 Veterans Fishing Challenge…Please note, due to inclement weather conditions,  the Date of the Event has been rescheduled to Saturday, March 11th

***Note, registrations submitted after 12/1/16 will be added to the wait list as we have reached capacity for the boat. We will contact you via the phone number provided the week of the event to confirm your availability and inform the wait list if an opening has allowed their inclusion***

Your Name (required)

Your Email (required)

Address

City,State, Zip

Phone

Do you have a physical impairment? If yes please provide details below.
YesNo

Disability Rating (%)

Questions or comments?

Having acquainted myself with the Challenge Rules, I have completed this application and submit it for entry into the 2016 Veterans Fishing Challenge. In submitting this application, I agree to be bound by and comply with all Rules and Regulations. I expressly assume all risks associated with this Challenge, and hereby release the Melbourne Regional Chamber, its Officers, the host, sponsors, officials and any other organizations involved in the Challenge from all claims of injury and/or damages incurred in connection with this Challenge. I further understand and agree that the Challenge Committee reserves the right to reject my application for any reason.