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Captain______________________________________________________________________
Address______________________________________________________________________
Street City State Zip
Phone Number________________________________________________________________
Captains Signature____________________________________________________________
I hereby grant the Burkettsville Picnic committee and its legal representatives and assignees the irrevocable and unrestricted rig hts to use and publish
photographs of me, or in which may be included, for editorials, trade, or advertising and nay other purpose and in any other manner or medium. I hereby
release the Burkettsville Community Picnic Committee and its legal representatives and assignees from all claims and liability to said photography.
I have read the forgoing and am of age to consent to this waiver. If you are under age, your parents must also sign this paper by
your name giving you (the under age) permission to participate in the above activity. Also, by signing this paper you are also
releasing all personal and bodily injuries from the Burkettsville Community Picnic Committee and its legal representatives fr om
all liability. Underage people must also provide their home phone number.
1. _____________________________ 7. ________________________________
PAYOUT BREAKDOWN
13-16 TEAMS
1ST - $600
2ND – $400
3RD - $240
4TH - $100
11-12 TEAMS
1ST - $500
2ND - $300
3RD - $160
8-9 TEAMS
1ST - $400
2ND - $240
3RD - $160
6-7 TEAMS
1ST - $300
2ND - $160
3RD - $100