Destination Depart Return WIND

Name & Hailing Port Legendary waters Casino Marina slip 36

Document / Registration No. MN6749MD expires 12/31/23 Year, Make & Model 2000, Tiara, 3100 OPEN, Length 31ft, Type power Twinn Diesel B6, 3ft draft

Name Captain Shelly Holland

Address 2501 183rd ave NW oak Grove MN 55011 Age 54 Gender Female

Radio Call Sign Into Wishin

Fuel Capacity 200 Gallons

GPS / marine radio, Depth Sounder Radar all on board

Home Phone 612-805-7454

If there are any medical conditions you think the Captain should know about please list them by your name

Names of persons on board: Age Weight Telephone number

I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS EVENT.

please print then sign name.

Emergency Contact