NAME: _____________________________________________________________________ |
ADDRESS: __________________________________________________________________ |
_____________________________________________________________________________ |
PHONE NUMBER ________________________ |
DATE OF BIRTH __________________________ |
I, ____________________________, Have voluntarily elected to participate in the Polar Bear Swim fundraiser. I fully understand the risks of jumping into the waters of Casco Bay in February. I agree not to hold the Chebeague Recreation Center liable for injuries acquired from my participation in this event. I hereby confirm that I am in good physical condition and do not suffer from any disabilities or physical condition that places me at risk or otherwise prohibits my participation in the Polar Bear Swim. Furthermore, in consideration of my participation in this program, I myself, my heirs and assigns, release the Chebeague Recreation Center and the Chebeague Island Boat Yard (employees, officers, or volunteers), from any claims, demands, and/or causes of action arising from my participation in this event. I hereby affirm that I fully understand the preceding paragraphs
and volunteer to participate at my own risk. Paritcipant: _________________________________ Witness: ___________________________ Signature: __________________________________ Signature: ___________________________ Date: ______________________ Signature of Parent or Guardian: ____________________________________________________ |