Participants Name: ___________________________________________________________________
Address: _____________________________________________________________________________
City: ____________________________________________ State: _______ Zip Code __________
Phone: ___________________
Emergency Contact Name: __________________________ Ph#______________
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 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: ________________________________________