“Burkettsville Community Picnic” 6th

Annual “CO-ED” Mud Volleyball

Tournament
August 8, 2009 at 11:00 a.m.

Team Name: (please print)____________________________________

Captain____________________________________________________

Address____________________________________________________
Street City State Zip

Phone Numbers______________________________________________

Captains Signature___________________________________________

Mud Volleyball Waiver

All mud volleyball participants must sign this liability waiver. Any individual whose signature
does not appear on this form will not be allowed to participate, and therefore disqualifies that
individual from competition.
In consideration of my participation in Mud Volleyball competition, the undersigned independently and collectively, and on behalf of him/herself, their heirs,
personal representatives, and all those claiming by or through him/her, consent to, and does hereby, discharge, release, and hold blameless the Burkettsville Picnic
Committee and all the sponsors and affiliates, servants, employees, agents, assigns, and successors from any all claims, actions, damages, or expenses for
personal or bodily injury (including death) and property loss or damages incurred by him/her or arising out of or in connection with her/his participation on the
above mentioned Mud Volleyball Tournament to be held at the Burkettsville Park.

I hereby grant the Burkettsville Picnic committee and its legal representatives and assignees the irrevocable and unrestricted rights to use and publish photographs
of me, or in which may be included, for editorials, trade, or advertising and nay other purpose and in any other manner or medium. I hereby release the
Burkettsville Community Picnic Committee and its legal representatives and assignees from all claims and liability to said photography.

I have read the forgoing and am of age to consent to this waiver. If you are under age, your parents must also sign this paper by your name giving you (the under age)
permission to participate in the above activity. Also, by signing this paper you are also releasing all personal and bodily injuries from the Burkettsville Community Picnic
Committee and its legal representatives from all liability. Underage people must also provide their home phone number.

TEAM MEMBERS SIGNATURES. (Must have all signatures to be accepted).

1. _____________________________ 6. ________________________________

2.______________________________7.________________________________

3.______________________________8.________________________________

4.______________________________9.________________________________

5.______________________________10._______________________________
 “Burkettsville Community Picnic” 6th
Annual “CO-ED” Mud Volleyball
Tournament

FIRST PLACE---$400.00
SECOND PLACE--$250.00
THIRD PLACE---$150.00
FORTH PLACE---$100.00
WHO: First 16 Teams to sign up and pay. Must have registration forms turned in to
Doug Hemmelgarn to qualify. Email burkettsvillepicnic@hotmail.com for additional
sign-up sheets.

COST: $120.00 per team (Co-ed Team) Please make checks out to the Burkettsville
Community Picnic Inc.

SEND TO:
Burkettsville Community Picnic
P.O. Box 204
Burkettsville, Ohio 45310
419-375-1099

WHAT: Mud Volleyball Tournament in conjunction with the Burkettsville Community

Picnic

WHEN: Drawing Saturday, August 8th, 2009 at 10:30 a.m.

Play Saturday August 8th, 2009 at 11:00 a.m.

WHERE: Held at the Burkettsville Park (located behind the old school building) now the
St. Peter Neurological Center.
RULES
1. Eight men or women on the court at one time with at least two of opposite gender
on the court. Example: 6 men and 2 women, or 6 women and 2 men.
2. Must have waiver signed to play.
3. Rules of regular volleyball will be the same-including rotation of players.
4. In the event of an injury, the referee will stop the game, and a substitute can be
made.
5. Head referee has the right to stop the game or the clock at their discretion.
6. It is single elimination tournament unless 8 or fewer team sign up then it will be a
double elimination tournament.
7. Game goes to 21 points the first round and 15 points the remaining rounds. All
scoring will be done by rally scoring.
8. Shoes must be worn (can be duct taped on) at all times.
9. The decisions of the referee are final.
 “Burkettsville Community Picnic” 6th
Annual “CO-ED” Mud Volleyball
Tournament
10. 1 PERSON FROM EACH TEAM MUST BE A LINE JUDGE FOR THE GAME
IMMEDIATELY FOLLOWING THE ONE THEY JUST PLAYED IN.
11. Must be on time or team will be disqualified for game missed.