Team Captain Name *

First Name

Last Name

Team Captain Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Team Captain Phone *

(###)

###

####

Would you like to participate in the following team events (in addition to the polar plunge)

Please check all of the activities your team would like to participate in

Snowball Dodgeball Tournament

Frozen Fingers Tug-of-War Tournament

Release of Liability: * I, on behalf of myself, my heirs, executors, administrators, and assigns, hereby release, discharge, and hold harmless Wellspring Multi-service Centers, its officers, directors, employees, volunteers, and sponsors from any and all claims, demands, actions, or causes of action, whether in law or equity, arising out of or related to my participation in the Wellspring Winter Warrior Games. This includes, but is not limited to, any injuries, illnesses, or damages that may occur before, during, or after the event. Photography and Publicity: I grant permission to Wellspring Multi-service Centers to use any photographs, videos, or other media taken of me during the Wellspring Winter Warrior Games for promotional purposes, without compensation. Emergency Medical Treatment: In the event of an emergency, I authorize Wellspring Multi-service Centers and its representatives to seek and consent to emergency medical treatment on my behalf. By Checking this box I have read and understand the terms of this waiver and release of liability. *