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2022 Youth Fishing Derby Boat Captain/Boat Assistant Registration (PUBLIC)

  1. IMPORTANT: Please open this form in GOOGLE CHROME (Internet Explorer fails to submit properly).
  2. Boat Captain Registration Form

    If you are interested in volunteering as a boat captain, boat assistant, or shore assistant, please complete the form below.

  3. Which are you signing up for?:*
  4. Which law enforcement/fire/EMS/other first responder agency/organization do you work for?
  5. T-shirt Size*
  6. Have you participated in this event in the past?
  7. Is there anything you'd like to make us aware of or special requests you may have for that day? We will try to accommodate as much as we are able.
  8. Liability Release
    I, the undersigned, hereby assume full responsibility for all risk of injury or loss which may result from myself or the participation of others in this activity, and hereby agree to hold harmless; release and forever discharge, the Scott County Sheriff's Office and all partners, vendors, and volunteers related to this event from any and all claims and demands whatsoever. I understand, agree and acknowledge that some activities may be of a hazardous nature and/or include physical and/or potentially strenuous activity. Understanding this, I state to the best of my knowledge that I have no medical, physical, mental, or emotional health conditions which would hinder my active participation in this event. In the case of an emergency in which I am not able to give permission for medical treatment, I authorize the staff or agents of the Scott County Sheriff's Office, and all event volunteers, to obtain whatever medical treatment he/she deems necessary for my welfare. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency medical treatment, regardless of whether my medical insurance would cover such charges and fees.
  9. I have read and agree to the Liability Release*
  10. Photo & Video Release
    During this Youth Fishing Derby event, I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio, video, or other media without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. By signing this release I understand this permission signifies that photographic or video recordings of me and may be electronically displayed via the Internet or in the public setting. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By typing my name below, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for promotional and/or educational purposes.
  11. Do you agree to the Photograph & Video Release?*
  12. Data Practices Rights Advisory
    As an applicant for a Boat Captain with the Sheriff’s Office, you are being asked to provide information about yourself, which will be used in consideration of your application. The purpose of this request for information is to obtain information about you to permit the Sheriff’s Office to complete local and State of Minnesota background check(s), outstanding warrant(s) checks, and when applicable, to ensure that you possess a valid Minnesota driver's license. You are being requested to sign these documents and complete the information in order to be considered as a Boat Captain. The data you are being asked to provide is defined under the Minnesota Government Data Practices Act. Under the Data Practices Act, some of this data is classified public data and the remaining information is classified as private data or confidential. As a result of the classification of this data, the Scott County Sheriff’s Office will not release to any person other than public officers and agencies who have a need to know such information in order to process and make a decision on the approval of your application. The purpose and intended us of the information provided to the Sheriff’s Office is to determine whether authorization to be a Boat Captain should be approved. If authorization is granted to become a Boat Captain, the data supplied by the applicant will become public. Public data is data that is available to any person upon request. The release of information that you have signed and the data you provide maybe conveyed to third parties. To the extent they reveal private information; they will be disclosed only to the extent that is necessary to complete the required application processing.
  13. I have read and understand the above Data Practices Rights Advisory*
  14. Thank you for your interest becoming a Boat Captain for the Youth Fishing Derby! Your information will be forwarded to the event coordinator. You will be notified shortly as to whether your request can be accommodated. If you have any questions, please contact Dennis Tietz at 952-496-8724 or dtietz@co.scott.mn.us.
  15. Leave This Blank:

  16. This field is not part of the form submission.