Mexia Bass Club

Individual: _________

                  $20.00

Family: _________

              $30.00

Member:s Name: ______________________________________________________________________________________

Mailing Address: ______________________________________________________________________________________

                            City: ______________________________________ State: ______________________  ZIP:  _________

Home #:  _______________________      Work #: ________________________       Cell #:  ________________________

Family Member’s Name:  ______________________________________________________________________________

Partner’s Name:  _____________________________________________________________________________________

ARTICLE 11, SECTION 1:

“EACH CLUB MEMBER AND/OR GUEST IS SOLELY RESPONSIBLE FOR HIS OR HER OWN ACTIONS, INCLUDING SITUATIONS THAT RESULT FROM INCLEMENT WEATHER.  THE MEXIA BASS CLUB AND/OR ITS OFFICERS WILL NOT BE HELD LIABLE FOR BOATING, WATER, TRAVEL, OR ANY OTHER ACCIDENTS.”

SIGNATURE OF MEMBER:  ___________________________________________________________________________

Email Address:  ______________________________________________________________________________________

Date:  _______________________________________________________________________________________________

Release to allow name and pictures on website:    ____ OK            ____ NOT OK

                        Supporting  Fish Conservation                                                Catch and Release

PLEASE PRINT LEGIBLY!