Participant Registration-2022 Polar Bear Jump & 5K Race/Walk

Please complete the following Participant Registration & Waiver Form to sign-up for the 2022 Polar Bear Jump & 5K Race/Walk, February 19, 2022. After completing the Waiver Form, click Continue to proceed to registration payment ($30) via PayPal to complete your registration for the event.

Participant (Jumper-5K Race/Walker) First Name Participant (Jumper-5K Race/Walker) Last Name Participant Email Address If (Jumper-5K Race/Walker) is Under 18 -Please Enter Parent/Guardian Name

Jumper/5K Race-Walker/Both Jumper 5K Race/Walker Jumper & 5K Race/Walker

Participant (Jumper-5K Race/Walker) Date of Birth

Gender Male Female

Phone Number Address 1 Address 2 City State Zip

I UNDERSTAND THAT A PARTICIPANT REGISTRATION FEE IS REQUIRED TO JUMP & 5K RACE/WALK

Participant Registration (Select to Register) 2022 Polar Bear Participant Registration ($50 USD)

Free T-Shirt with Registration-Please choose your T-Shirt Size

Would you like to buy $50 raffle ticket? 1st Prize $3,000, 2nd Prize $1,500 3rd Prize $500 Goodyear Gift Certificate No 1 x $50 Raffle Ticket ($50 USD) 2 x $50 Raffle Tickets ($100 USD) 3 x $50 Raffle Tickets ($150 USD) 4 X $50 Raffle Tickets ($200 USD) 5 x $50 Raffle Tickets ($250 USD)

Open this link to agree with Open this link to agree with Waiver Release Terms

Initial below to agree with Waiver Terms above.

Voluntary Participation Terms:I am voluntarily participating in the Event with full knowledge of the inherent risks, hazards and dangers involved and hereby assume and accept any and all risks of injury, paralysis or death, and agree to abide by all Polar Bear Plunge rules, regulations and guidelines. I hereby confirm that I am in good physical condition and do not suffer from any disabilities or physical conditions that place me at risk or otherwise should prohibit my participation in the Chippewa Lake Polar Bear Event.

Initial below to agree with the Voluntary Participation Terms above.

Open this link to agree with Hold Harmless Terms

Initial below to agree with the Hold Harmless Terms above.

No Diving Policy: I agree that the Chippewa Lake Lions Club reserves the right to remove me from the water, at any time, for any reasonable cause. I agree that I will enter the water feet first. I understand that no diving is permitted.

Initial below to agree with the No Diving Terms above.

No Pet Policy: I understand that the Chippewa Lake Lions Polar Bear Event does not allow pets. I agree by my initials below, not to bring my pet(s) to the Polar Bear Event.

Initial Below to agree with the No Pet Policy

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. Open this link to agree with the Waiver, Release and Indemnification Agreement

Signature of Parent or Guardian (Type Name) Date of Signature of Parent or Guardian

Name of Minor Minor Date of Birth

Photo Release Terms:I understand and agree and hereby give my consent to the Chippewa Lake Lions CLub Foundation, Chippewa Lake Lions Club or any sponsor to use my photograph or likeness in any Chippewa Lake Lions Club Foundation, Chippewa Lake Lions Club or sponsor’s hard copy and/or electronic publications, including Websites. I release them from any expectation of confidentiality or compensation for myself and any undersigned minor and attest that I am the Parent or Guardian of said minor listed below.

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 2nd 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