27th ANNUAL

BROKEN NECK TROUT CAMPOUT REGISTRATION FORM

8 thru 11 September 2011

click HERE for a printable PDF of the registration form

The information requested within the box must be completed.

The information requested within the box must be completed.
 IF YOUR REGISTRATION IS INCOMPLETE, IT WILL BE RETURNED TO YOU UNPROCESSED. IF YOU STILL DESIRE TO ATTEND, RESUBMIT A COMPLETED REGISTRATION FORM. If you are not attending this campout and have not attended since 2007 and desire to continue receiving announcement flyers, please return this form with items 1, 3, 4.c and 5 completed.

 

     1. YOUR NAME:
2. YOUR DATE OF BIRTH:
         If you are under 18 years of age, the form on page 2 must be completed and signed by          
         your parent or legal guardian.
     3. YOUR COMPLETE MAILING ADDRESS:

4. PHONE NUMBERS, INCLUDING AREA CODE

  1. Emergency contact name:
  1. Emergency contact telephone number:

 

  1. Your contact telephone number:

  5. E-MAIL ADDRESS: ________________________________@______________________
If you have any questions regarding registration, please contact me at brokennecktrout@aol.com   Thank you for your help and understanding.

6. Is this your first campout? _______________ If so, who is your campout sponsor? ________________________
7. How many campouts have you attended? ______________
8. How many years of sobriety? __________________

$_______________CAMPING FEES: $75.00 for 8 thru 11 Sep 2011. If you are arriving early, make arrangements directly with Pine Cliff Resort.

$_______________ GOLF FEES: ($90.00) Please note: The golf fee only covers the green fees at Sierra Star.
Please indicate shirt size _____ . Please indicate handicap or low score broken.
Handicap_____.  Broke 100 ___. Broke 90 ___. Broke 80 ___. Broke 70 ___.
(OVER)
(Golf, continued)
All prizes, trophies, etc are donated by the players. Please contact Mike Kreger, in
Bakersfield at 559-647-7705 or Rufus Ethington, in San Diego at 619-890-6894, if you have items to donate.

15 August 2011 is the cutoff date for registration. Your registration must be in by that date to give us time to order the provisions.
Thank you for your help and assistance.

 

Make your checks or money orders payable to:

Broken Neck Trout Campout

P.O Box 180399

Coronado, CA 92178

THIS FORM MUST BE COMPLETED BY PARENT OR GUARDIAN OF A CAMPER UNDER THE AGE OF 18.

I hereby authorize (camper’s name)_______________________________
to participate in all functions involved with the Broken Neck Trout Campout, including transportation to and from the event. I further authorize any medical treatment deemed necessary, by competent medical authority, for the health, welfare or safety of the camper and that I will be responsible for any costs involved for that treatment. I specifically hold harmless any member or participant of the Broken Neck Trout Campout.

 

Parent or Guardian’s signature

 

 _____________________________________________________________
Notary’s signature and seal

 

ONLY ONE REGISTRATION PER FORM

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