2015

PLUNGE FOR DUBOIS COUNTY

Ferdinand State Forest

Sunday Feb. 15, 2015 Be There at 2:00 EST

We Plunge at 3:00 EST Funds Raised will Benefit the following: Lange-Fuhs Cancer Center, Dubois County Leukemia Association, and area Food Banks.

Contact: Eric Uebelhor -639-9895 [email protected] or [email protected] Jay Fischer - 309-4196 [email protected] All participants must sign the Waiver and Release form. If you are under the age of 18 a parent or guardian must sign Waiver and Release form.

Cost is $20 per person(receive a t-shirt) +$50 in Pledges(receive a towel) Tips for Plunging #1 Bring

a robe...great for putting on while waiting to go in and even better as you come out!

#2 Keep

your feet covered until the last possible moment.

#3 Bring

an extra towel or a blanket to stand on.

#4 Wear layered, loose fitting clothes.... they’re easier to get into with cold fingers!

#5 NO

DIVING or ENTERING THE WATER HEAD FIRST!



Plunger’s Name _____________________Phone______________ T-shirt size ________Call Eric 639-9895 or Jay 309-4196 with your shirt size. (Plungers who get $50 in pledges get a free towel! )

Donor’s Name

Phone

Amount

1) _________________________________________________ 2) _________________________________________________ 3) _________________________________________________ 4) _________________________________________________ 5) _________________________________________________ 6) _________________________________________________ 7) _________________________________________________ 8) _________________________________________________ 9) _________________________________________________ 10) _________________________________________________ 11) _________________________________________________ 12) _________________________________________________ 13) _________________________________________________ 14) _________________________________________________ 15) _________________________________________________ 16) _________________________________________________ 17) _________________________________________________ Pledge money to be turned in on the day of the Plunge Feb. 15, 2015.

WAIVER OF LIABILITY, HOLD HARMLESS, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT PLEASE READ CAREFULLY PRIOR TO PARTICIPATION IN THE POLAR PLUNGE FOR DUBOIS COUNTY Please be aware that there are certain risks involved in participation in this program/event. By tendering this completed, signed form, on my behalf or on behalf of my minor child/children, I assume full risk of injuries, death, paralysis, disability, damages or losses which I and/or my minor child/children may sustain. I agree to waive my rights and/or the rights of my minor child/children to all claims for injuries and/or death that I and/or my minor child/children might sustain arising out of participation in this program/event. I and/or my minor child/children fully release and discharge St. Anthony, Pine Ridge, and Ferdinand Youth Football League (SP&F) from any and all claims due to my actions or inactions and/or the actions or inactions of others. I and/or my minor child agree to fully indemnify, hold harmless and defend SP&F against all claims, complaints and lawsuits. I represent that I and/or my minor child/children are in good health and proper physical condition to participate in the Polar Plunge for Dubois County. I agree to immediately discontinue participation in the Plunge if I believe that event conditions are unsafe. I further understand that due to the nature of the Polar Plunge for Dubois County, there are risks, some of which are known and some of which are unknown, to me and/or my minor child/children, and I assume responsibility for all known and unknown risks on my own behalf and/or on behalf of my minor child/children. I agree to fully abide by all rules and conditions explained to me and I agree to cease participation in this event if asked to do so by any of the event coordinators. By my signature hereon, I fully release and discharge the following from all liability, action or inaction, claims, demands, losses or damages on my behalf and/or on behalf of my minor child/children: St. Anthony, Pine Ridge, and Ferdinand Youth Football League (SP&F), their administrators, directors, agents, officers; Volunteers; Other participants; Spectators; Sponsors; Advertisers; The Ferdinand State Forest and its employees; All individuals and entities involved in rescue operations. Payment of the Fee to participate in this event is the consideration for this Agreement and participation in this event/program is the benefit received.

I VERIFY THAT I HAVE FULLY READ THE ABOVE AGREEMENT AND I FULLY UNDERSTAND THE TERMS THEREOF AND I AGREE TO BE BOUND BY SAID TERMS. I AM SIGNING THIS AGREEMENT FREELY AND WITHOUT INDUCEMENT OF ANY SORT. IF ANY PORTION OF THIS AGREEMENT IS FOUND TO BE UNENFORCEABLE, ALL OTHER PROVISIONS SHALL BE ENFORCEABLE.

MY SIGNATURE HEREON IS AN UNCONDITIONAL RELEASE OF ALL CLAIMS AND LIABILITY, AS ALLOWED BY THE LAWS OF THE STATE OF INDIANA. IF I AM SIGNING THIS AGREEMENT ON BEHALF OF MY MINOR CHILD/CHILDREN, MY SIGNATURE HEREON IS, ON BEHALF OF MY MINOR CHILD/CHILDREN, AN UNCONDITIONAL RELEASE OF ALL CLAIMS AND LIABILITY, AS ALLOWED BY THE LAWS OF THE STATE OF INDIANA. I HAVE READ AND FULLY UNDERSTAND AND AGREE TO THE ABOVE STATED CONDITIONS OF THIS WAIVER OF LIABILITY, HOLD HARMLESS, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS AGREEMENT I AM GIVING UP SUBSTANTIAL RIGHTS AND I FULLY UNDERSTAND THE RIGHTS THAT I HAVE GIVEN UP AND THE RISKS THAT I HAVE ASSUMED, ON MY BEHALF AND/OR ON BEHALF OF MY MINOR CHILD/CHILDREN.

________________________________________ Signature of Participant ________________________________________ Printed Name of Participant Date: _____________________ FOR ALL PARTICIPANTS UNDER AGE EIGHTEEN (18): _______________________________________ Printed Name of Participant _______________________________________ Signature of Parent _______________________________________ Printed Name of Parent Date: ______________