NAME OF PARTICIPANT
MAILING ADDRESS
Email
PHONE NUMBER
EMERGENCY CONTACT PERSON
RELATION
EMERGENCY CONTACT PHONE NUMBER
IS YOUR EMERGENCY CONTACT PERSON ATTENDING WITH YOU?
YES
NO
DATE OF BIRTH (PARTICIPANTS MUST BE 18 YEARS OR OLDER)
AGE AS OF TODAY
DO YOU HAVE ANY PHYSICAL/HEALTH ISSUES THAT WE SHOUD KNOW ABOUT WHILE YOU ARE PARTICIPATING IN THIS PLUNGE?
YES
NO
IF YES, PLEASE DESCRIBE:
Date of Application
I have SEEN AND AGREED to the RELEASE INFORMATION. Participant Signature (MUST BE 18 YEARS OR OLDER) , (ORIGINAL SIGNATURE REQUIRED AT CHECK‐IN!)
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POLAR BEAR PLUNGE OR CHICKEN FUN RUN “STAGE” NAME
HOBBIES, LIKES, DISLIKES, SINGLE, POLITICAL PREFERENCE...WHATEVER...JUST GIVE US SOMETHING TO TELL ABOUT YOU!!!
WHY THE HECK ARE YOU DOING THIS BESIDES THAT IT’S A FUND RAISER?
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