OFFICIAL REGISTRATION FORM
FISH DERBY 2017
SATURDAY, JUNE 24 ~ 7:30 am – 11:00 am
Sponsored by Amarillo Parks and Recreation
*PLEASE PRINT * PLEASE PRINT * PLEASE PRINT * PLEASE PRINT * PLEASE PRINT * PLEASE PRINT*
Phone Number: ( ) / Parent/Guardian Name:Parent/Guardian Email:
Address: / City, St: / Zip:
ONLY CHILDREN 16 & UNDER ARE ALLOWED TO REGISTER FOR THIS EVENT
Child’s First Name: / Last Name: / DOB: /Age:
/M / F
What school do you attend? / /Child’s First Name: / Last Name: / DOB: /
Age:
/M / F
What school do you attend? / /Child’s First Name: / Last Name: / DOB: /
Age:
/M / F
What school do you attend? / /Child’s First Name: / Last Name: / DOB: /
Age:
/M / F
What school do you attend? / /Address: / City, St: / Zip:
How did you hear about this event? (Circle one) TV Radio Flier/Mail Flier/School Website Friend Newspaper
Water Bill Poster Store: Park/Gym Site:
Is this your first time to attend fish derby? (circle one) Yes / No
ETHNICITY (optional / circle one): Asian Hispanic/Latino Native American White Black Other:______
FISHING POLES: How many fishing poles do you need? KIDS ONLY #______(See below)
Fishing poles for use on June 24, 2017 only. Fishing poles are limited, therefore will be LOANED on a first come - first serve basis.
ADULTS ATTENDING: How many adults will be attending with this child? #______(See below)
If you are registering more than one child, please list the adults attending on ONE form only.
Deadline for pre-registration is 12:00 pm on Thursday, June 22, 2017. Return this form as soon as possible.
For more information, contact Amarillo Parks and Recreation at 378-9391 or email us at
Do you need transportation? Transportation is provided from/to the sites listed below. Pick up time is between 7-8am. A Parks and Recreation employee
(circle one) will be at each site to supervise children until the bus arrives. Children will return to the site between 11am and 1pm.
Yes / No Adults are welcome to attend, but not required. Check here______if the adults will ride the bus with the child. List the
# of ADULTS attending with child______
Circle one park where you would like your child to be picked up:
AvondaleSW 15th and Westgate / Benton
SE16th & Vernon / Bones Hooks
NW 20th & Hughes / East
SE 8th & Williams / Eastridge
NE 14th & Evergreen / El Alamo
SE 16th & Houston / My child will ride the bus but I will pick them up
Forest Hill
NE 10th & Grand / Gene Howe
Pico & Lamount / Glenwood
SE 27th & Roberts / Hamlet
Oak & Sycamore / Lawndale
SE 22nd & Bivens / Memorial
SW 24th & Washington
Mesa Verde
N. Vernon & Beaver St / San Jacinto
SW 2nd & Louisiana / Southlawn
SW 44th & Cline / Sunrise
SE 14th & Eastern / Will Rogers Amarillo Blvd & Buchanan
Do you need assistance or special transportation aids? (circle one) Yes / No
Mail or fax this form to: Amarillo Parks and Recreation, PO Box 1971, Amarillo, TX, 79105, or fax to 378-3568
Release of Liability/Photo Release
As a parent/legal guardian of above child (s), I certify that said child (s) has my permission to attend and participate in the above mentioned Fish Derby sponsored by Amarillo Parks and Recreation on/at the above date, time, and location. In signing this form, I hereby waive and release all other participants, hosts, sponsors, and all other officials/parties involved in the Derby from all claims, injury, and/or damage incurred in connection with this Fish Derby. I also hereby grant the sponsor and co-sponsor the unconditional right to use the name, voice, and photographic likeness of the child in connection with any of their audio/video promotions, articles, or press releases, but not as an endorsement.
Parent/Legal Guardian Signature ______Date______
** Please call 378-9391, and press 0 to confirm we received your registration form**
M Drive – Parks – Events – Fishing Derby – 2016 – Registration – Fish Derby Registration Form 2016