Annual Matt Brink Memorial Crazy Swede Polar Bear Swim
2018 Polar Bear Registration Form

Participants Name: ___________________________________________________________________

Address: _____________________________________________________________________________

City: ____________________________________________ State: _______ Zip Code __________

Phone: ___________________

Emergency Contact Name: __________________________ Ph#______________

Agreement, Waiver, and Release

I here by waive, release, and discharge any and all claims for damages for personal injury, death, or property damage which may have, or which may hereafter accrue to me as a result of participation in the Viking Polar Bear Swim. It is understood that this activity involves an element of risk and danger of accidents and knowing those risks I hereby assume those risks.

I am aware that this is a release of liability between myself and Ingjald Lodge #65 and sign it of my own free will.

Signature of Participant : _________________________________________

Parental/Legal Guardian Consent

Parental/Legal Guardian Consent for Participants ages 16 to 18: I hereby consent that my son/daughter _______________________________ participate in the Polar Bear Swim, and I hereby execute the above Agreement, Waiver, and Release on his/her behalf. I state that said minor is physically able to participate in said activity.

Signature of Parent/Guardian: ________________________________________