Name - ________________________________        Date - ___________________

Address - ______________________________

               _______________________________

Phone # - ______________________________

E-mail -   _______________________________

Memberships run from January 1^st – December 31^st

Single membership Fee - $25.00 annual - $30.00 family – Under 16 Free

All membership fees will be used for series expenses and promotional fees.

I have read and understand all of the KCA rules and regulations.  By signing below, I agree to abide by these rules and be governed as stated in these rules and regulations.  By signing below, I also hereby release KCA, KCA officials, participating members, any hosting officials and their employees, sponsors and local, state and federal officials from any liability due to injury, damage, theft, accidents or loss of life that may occur at any KCA function.  Official rule changes made prior to an event take precedence over any prior written rules.  All decisions made by the governing KCA officials concerning rules violations will be final.

Signature - ____________________________    Date - _______________________

Kentuckiana Catfish Association

Non-profit Organization

c/o  Mike Samuels

650 Samuels Ln.

Shepherdsville Ky. 40165

502-543-8213 Cell: 502-396-4007