2010 Sixth Annual Penguin Plunge Registration Form

Posted September 19th, 2008 by admin

Join us in supporting the kids of Western Massachusetts by taking the Penguin Plunge to benefit the Amelia Park Children's Museum. TAKE THE PLUNGE on Saturday, January 30th, 2010! (Inclement weather date: TB details available at www.CBS3springfield.com)

Last Name:

First Name:

Age:

Address:

City:

State:

Zip:

Email Address:

T-Shirt Size:

Small

Medium

Large

X-Large

Are you a student? You must have an I.D.:

Yes

Do you accept the terms?:

Yes

In consideration of accepting this entry, I, the undersigned, intending to be legally bound, hereby, for myself, my heirs, and executors, waive and release any and all rights and claims for losses and damages I may have against the sponsors of this event, town or state police, fire departments, and their representatives, successors and assigns, for any and all injuries suffered by me and said event. Further, I hereby grant full permission to any and all the foregoing to use photographs, videotapes, motion pictures, recordings or any other record of this event for any purposes whatsoever.