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Participant Registration for the Polar Bear Jump-Fun Run Walk > Step 1 of 2: Submit

Participant Registration for the Polar Bear Jump-Fun Run Walk

Please complete the following Participant Registration & Waiver Form to sign-up for the January 26, 2013, Polar Bear Jump-Fun Run/Walk. Click Continue to proceed to registration payment ($25) via PayPal to complete your registration for the event.

Participant (Jump-Fun Run/Walk) First Name *

Participant (Jump-Fun Run/Walk) Last Name *

Participant Email Address *

If Jump- Fun Run/Walker is Under 18 -Please Enter Parent/Guardian Name

Corporate Challenge Trophy. New this year is the Corporate Challenge. Have a Jumper-Runner/Walker from your company register and then have company employees chip in to sponsor the contestant.

The Largest Corporate Fund Raiser will win the 1st Annual Corporate Challenge Trophy.

Are You a Corporate Challenge Participant? *

YES
NO

Corporation Name for the Corporate Challenge

Jumper/Fun Run-Walker/Both *

Jumper
Fun Run/Walker
Jumper and Fun Run/Walker

Participant (Jump-Fun Run/Walk) Date of Birth *

Phone Number *

Address 1 *

Address 2

City *

State *

Zip *

I UNDERSTAND THAT A PARTICIPANT REGISTRATION FEE IS REQUIRED TO JUMP AND FUN RUN WALK

Participant Registration (Select to Register) *

Participant Registration ($25 USD)

T-Shirt Size *

Open this link to agree with Waiver Terms

Intial below to agree with Waiver Terms above. *

Open this link to agree with Voluntary Participation Terms

Intial below to agree with the Voluntary Participation Terms above. *

Open this link to agree with Hold Harmless Terms

Intial below to agree with the Hold Harmless Terms above. *

Open this link to agree with No Diving Terms

Intial below to agree with the No Diving Terms above. *

I HAVE CAREFULLY, CLEARLY UNDERSTAND AND VOLUNTARY SIGN THIS WAIVER AND RELEASE AGREEMENT AND ACKNOWLEDGE THIS AGREEMENT BY COMPLETING ALL INFORMATION BELOW ..

Participant Signature-Type Your Name *

Date of Signature *

Emergency Contact Name *

Emergency Contact Phone Number *

Individuals 11 years of age or older may participate. A Parent or Legal Guardian must sign below after reading the following Waiver Release and Indemnification

Signature of Parent or Guardian (Type Name)

Date of Signature of Parent or Guardian

Name of Minor

Minor Date of Birth

Open this link to agree with Photo Release Terms

Photo Release Participant Signature (Type Your Name) *

Date of Photo Release Signature *

1st Photo Release Minor Name

Date of Birth of 1st Photo Release Minor

2nd Photo Release Minor Name

Date of Birth of 12nd Photo Release Minor

3rd Photo Release Minor Name

Date of Birth of 3rd Photo Release Minor

4th Photo Release Minor Name

Date of Birth of 4th Photo Release Minor

* indicates required fields

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