TAKE A DIP FOR DOZER

Waiver Form

February 11, 2012 Registration at 11:00 – 1:00 p.m.- LAKE RIPLEY PARK

Name:  __________________________________________________________________________________

Address:  ____________________________________City ________________________State_______Zip__________

Phone Number:  _______________________________   Date of Birth:   ____________________________

I recognize and acknowledge that there are risks of physical injury and I agree to assume the full risk of any injuries, damages or loss I may sustain as a result of participating in any and all activities associated with the “Take A Dip For Dozer” fundraiser February 11, 2012. 

I, the undersigned, assume full responsibility for any risk of bodily injury, death or property damage arising out of or related to the “Take a dip for Dozer” whether caused by the negligence of the Cambridge Foundation, CAP, Cambridge Fire Department, Cambridge EMS, Cambridge Athletic Boosters, Cambridge Gridiron, Cambridge School District, any additional sponsors or the Zuelsdorf family or otherwise.

I acknowledge the risks of jumping into Lake Ripley on February 11, 2012 and understand the risks associated with submitting myself to very cold water and ice. I also acknowledge that any photos taken may be used for promotional purposes.

I hereby agree to indemnify and save and hold harmless the Cambridge Foundation, Cambridge Fire Department, Cambridge EMS, Cambridge Athletic Boosters, Cambridge Gridiron, Cambridge School District, any additional sponsors or the Zuelsdorf family (employees, volunteers, officers or sponsors) and each of them from any loss, liability, damage or cost they may incur arising out of or related to the “Take a Dip for Dozer” whether caused by the negligence of the groups and individuals listed above or otherwise.

I hereby affirm that I fully understand the preceding paragraphs and voluntarily choose to participate at my own risk.

Participant:  ____________________________________    Witness: _____________________________________

                        (print name)                                                                 (print name)

Signature:  _____________________________________     Signature:  ___________________________________

Signature of Parent or Legal Guardian if under age 18:_______________________________________________

Notary Public Guarantee Required for Parent or Legal Guardian Signature

  Notary Public:_________________________________County of:______________, WI.  Expires: _____________

**Pledge forms and signed waiver forms (must be signed by participant and witness) and must be turned at in registration   on February 11, 2012.  You can not take the “Dip” without these documents.    

Questions can be directed to Jana Evans at 608-423-3241 or 608-423-2013