Potomac River
Junior Invitational
Sunday June 18, 2006
Smallwood
State Park
Maryland
A
Maryland
BASS Federation
Hosted Event
Date:
________________
State Team: __________________________
Applicant (full name): ____________________________________
Age: _______ Date of
Birth: _________________
Street Address: ____________________________________
City: ____________________________ State:
_________ Zip: ______________
Phone: (home) _____________ Email
Address: _______________________
Parent(s)
full name(s): ______________________________________________
Parents’ Signature(s): ______________________________________________
Name of Youth Club: _____________________________
Name of State Youth Director: ___________________________
Mail to:
Randy Dotson
2nd Vice President
Maryland
Bass Federation
7780 Arborview Drive
Charlotte
Hall, MD 20622