- APCM Penguin Plunge

11th Annual
2015 REGISTRATION FORM
Saturday, January 31, 2015
Hampton Ponds State Park
Rt. 202, Westfield, MA
Last Name: ____________________ First Name: __________________ Age: ________
Address: _________________________________________________________
City: ______________________________ State: __________ Zip: ___________
Phone: _________________________________
E-mail: _________________________________
(please print clearly)
T-shirt Size: _____________________
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 of the foregoing to use
photographs, videotapes, motion pictures, recordings or any other record of this
event for any purposes whatsoever.
Signature of Plunger: ______________________________________________________
Signature of Parent/Guardian: ______________________________________________
** If Plunger is 17 or younger **
PRE-REGISTER OPTIONS
FAX or MAIL this completed Registration to APCM (address below)
OR Save & Email your registration form to: [email protected]
CHECK IN: turn in Donations and pick up your pre-plunge merchandise
Friday, January 30th between 6:00pm and 8:00pm at the APCM
Saturday, January 31th between 11:30am & 12:00 noon at
Hampton Ponds State Park, Rt. 202, Westfield, MA
Reset Form
Submit
Amelia Park Children’s Museum 29 South Broad Street, Westfield, MA 01086 | FAX 413.572.1206
11th Annual
2015 REGISTRATION FORM
Saturday, January 31, 2015
Hampton Ponds State Park
Rt. 202, Westfield, MA
NOTE: Must reach a minimum of $50 in pledges in order to participate in the Penguin Plunge.
You may order an official Penguin Plunge t-shirt with a minimum of $75 in pledges.
NAME
ADDRESS
AMOUNT
$ 0.00
Amelia Park Children’s Museum 29 South Broad Street, Westfield, MA 01086 | FAX 413.572.1206
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