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: fun@ameliaparkmuseum.org 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