Lawrence County Habitat for Humanity Release and Waiver of Liability, Assumption or Risk, and Indemnity (“Agreement”): In consideration of participating in the
Lawrence County Habitat for Humanity Plunge (Activity), (1) represent that I
understand the nature of Plunging events and that I and/or my minor child am
qualified, in good health, and in proper physical condition to participate in such
Activity. I acknowledge that if I and/or my minor child believe, know or should
know that any conditions, situations or circumstances related to or arising out of
the Activity and/or related events are unsafe or are any risk to any person or
property. I and/or my child is/are/will be in good health, and in proper physical
condition to participation in the Activity. (2) I fully understand Plunging/Swimming
events involve risks of serious bodily injury, including permanent disability,
paralysis and death, which may be cause by my own actions, or inactions, those
of others participating in the Activity, the conditions in which the Activity takes
place, or the negligence of the “Releases” named below, and that there may be
other risks either not known to me or not readily foreseeable at this time; and (3)
I fully accept and assume all such risks and all responsibility for losses, costs,
and damages I and/or my child incur as a result of my and/or my minor child’s
participation in the Activity. (4) I hereby release, discharge, and covenant not to
sue Habitat for Humanity International, Lawrence Co. Habitat for Humanity, its
respective administrators, directors, agents, officers, volunteers, and employees,
other participants, any sponsors, advertisers, and, if applicable, owners and
lessors of premises on which the Activity takes place, (each considered one of
the “Releases” herein) from all liability, claims, demands, losses, or damages on
my account caused or alleged to be caused in whole or in part by the negligence
of the “Releases” or otherwise, including negligent rescue operations, and (5) I
further agree that if, despite this release, waiver of liability, and assumption of
risk, I, or anyone on my and/or my child’s behalf, makes a claim against any of
the Releases, I will indemnify, save, and hold harmless each of the Releases
from any loss, liability, damage, or cost which any may incur as a result of such
claim. (6) I have read the RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, AND PARENTAL CONSENT
AGREEMENT, understands substantial rights by signing it and have signed it
freely and without any inducement or assurance of any nature and intend it to be
a complete and unconditional release of all liability to the greatest extent allowed
by law and agree that if any portion of this agreement is held to be invalid the
balance, notwithstanding, shall continue in full force and affect.
_____________________________________________Print Name of Plunger
REGISTER NOW
5th Annual
Douse for a House
Polar Plunge
Get Ready to Plunge
COMPLETE REGISTRATION FORM-Mail registration
form with minimum deposit of $25 which counts
towards the full registration fee.
COLLECT-RECORD-MAIL-Ask your friends, family &
co-workers for donations. Mail checks or money
orders only to Lawrence County Habitat for Humanity, 138 W. Washington Street, New Castle, PA
16101. or bring the balance of your donation to
the Plunge. DO NOT SEND CASH THROUGH THE
MAIL. Sponsor’s check will serve as receipt.
WEAR-Bathing Suit and/or COSTUME highly recommended. NO WETSUITS ALLOWED. Bring a towel,
blanket or robe to wrap in after Plunging. Before
and after the Plunge, sweat suit apparel & warm
boots recommended. (Changing facilities may
NOT be available.)
EARLY REGISTRATION-Registrations received by
January 31, 2015 guarantee an official
long-sleeve Plunge t-shirt.
Saturday
February 14, 2015
ON-SITE REGISTRATION—$ 100 minimum to Plunge.
Students & Military $ 50 minimum to Plunge.
Plungers will receive a Plunge t-shirt while supplies
last.
_______________________________________________________________
Date
Signature of Plunger (Parent/Legal Guardian
if under age 18)
I N C E N T I V E S - Prizes awarded for top individual &
team fundraiser & best individual & team costume.
By my participation in this event I am granting permission to you to use my
name, likeness, voice and words in television, radio, films, newspapers, magazines, and other media, and in any form not heretofore described, for the purpose of advertising or communicating the mission and activities of Lawrence
County Habitat for Humanity in appealing for funds to support such activities.
NO ALCOHOL BEVERAGES
ALLOWED AT THE EVENT.
RETAIN THIS PORTION FOR YOUR RECORDS.
_____________________________________________Print Name of Plunger
_______________________________________________________________
Date
Signature of Plunger (Parent/Legal Guardian
if under age 18)
PLUNGE WITH A FRIEND–
IT’S MORE FUN!
In 2014, 78 plungers raised $26,000. These funds
remained in Lawrence County and provided
LCHfH with one-third of the amount needed to
provide a family in need with a home. Help us
increase that amount and make another family’s
dream come true.!! “Take the Plunge.”
INDIVIDUAL REGISTRATION
Plunger:____________________________________
First Name
Last Name
Address:____________________________________
City:
“DOUS E FOR A HO US E”
5th ANNUAL POLAR PLUNGE
WHEN: FEBRUARY 14, 2015
(Storm date: February 21, 2015)
WHERE: MORAINE STATE PARK
Pleasant Valley Beach Area South Shore
State:
Zip: ________
TEAM NAME___________________________________
Teams must consist of 6—10 members
Plunger:______________________________________
First Name
Last Name
Email:___________________________________________
Address:______________________________________
Cut
Here
And
Save
Age:
__ Date of Birth: _ ____/_____/___________
Please circle garment size (Adult Size Only)
S
M
L
XL
XXL
(If size is not selected, XL will be given. Sorry no exchanges)
REGISTRATION: 10:30-11:30AM
PLUNGE: 12:15
COSTUME CONTEST ~ 11:30
REFRESHMENTS & FOOD AVAILABLE
Dance with our D.J.
Spectators Invited To Cheer On The Plungers.
Questions? Call 724-652-3438 or email
[email protected]
TEAM REGISTRATION
Returning plunger
Yes or No
How did you hear about the Plunge?
________________________________________________
For $100 in sponsors/donations, each Pre-registered
Plunger receives the official long-sleeved Plunge
t-shirt, refreshments and all braggin’ rights
associated with such a brave endeavor.
City:___________________State:_____Zip:_________
Email:________________________________________
Age:___________Date of Birth:____/_____/_________
Please circle garment size (Adult Size Only)
S
M
L
XL
XXL
(If size is not selected, XL will be given. Sorry no exchanges)
Returning plunger
Yes or No.
How did you hear about the Plunge?
_____________________________________________________
MAIL THIS REGISTRATION FORM WITH
SIGNED WAIVER (LOCATED ON BACK OF
FORM) AND DEPOSIT OF $25 MINIMUM BY
JANUARY 31, 2015. You will receive a t-shirt if
registered by 1-31-15.
For $100 in sponsors/donations, each Pre-registered
Plunger receives the official long-sleeved Plunge
t-shirt, refreshments and all braggin’ rights associated
with such a brave endeavor.
PRIZES AWARDED FOR TOP INDIVIDUAL &
TEAM FUNDRAISER & BEST INDIVIDUAL &
TEAM COSTUME.
MAIL THIS REGISTRATION FORM WITH SIGNED
WAIVER (LOCATED ON BACK OF FORM) AND DEPOSIT OF $25 BY JANUARY 31, 2015. You will receive a
t-shirt if registered by 1-31-15
WALK-ONS WELCOME
Checks or Money Orders payable to:
Lawrence County Habitat for Humanity
138 W. Washington Street
New Castle, PA 16101
I am Team Captain . ONLY Team Captain checks in at
Team Registration. Captain presents all donations, will pick
up wristbands & t-shirts for the entire team on Plunge Day.
PRIZES AWARDED FOR TOP FUNDRAISING TEAM &
BEST TEAM COSTUME