LAST NAME:______________________________________________

FIRST NAME:_____________________________________________

ADDRESS:_______________________________________________

CITY:___________________________________________________

STATE:______________ZIP:__________________

PHONE # (     )___________________________________________

S.S.#___________________________________________________

Pre Registration fee $ 10.00 by April 30, 2005,

After May 1, 2005 $15.00

REGISTRATION FEE $______________________________

ELECTRIC SERVICE $______________________________

50/50 ENTRY         $______________________________

TOTAL ENCLOSED  $______________________________

Mail to: Kish Creek Trout Tournament, c/o

Teresa King,114 Pine St., Reedsville, PA 17084

 I hereby release the Kish Creek Trout Tournament,

 all participating organizations, and all participating

sponsors of the Tournament from any loss of property,

bodily injury, or loss of life that may occur in this Tournament.

SIGNATURE ___________________________________________

BADGE #___________________________________

                   (Official Use Only)