Registration Form: Please Print LegiblyName: _______________________________________________________

Youth Division: Yes or No (Circle One)

Address: _____________________________________________________________
City: __________________________________ State: __________ Zip:___________ Phone: ___________
Email: _____________________________
Signature: _________________________________________ Date: _______________ 
(Required for all; Parent signature required for youth division)Mail registration to: LVFD Ice Derby, PO Box 22, Massena, NY 13662Liability: Neither the tournament committee, sponsors, judges, officials, directors, or volunteers 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 whatever form or manner said liabilities or damages might be incurred. I understand that by signin this form I am fishing at my own risk.