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Presents

Chicken Dance & Chicken Plunge


Main Launch/Bandshell Area - Codorus State Park
Saturday, January 21, 2017 (snow date Saturday, January 28, 2017)
Registration Opens 10AM
Eagle Plunge 11AM-1PM Winter Festival 10AM-2PM
Chicken Dance & Plunge 1PM (just take a few steps into the lake)
MAIL YOUR COMPLETED REGISTRATION & PAYMENT TO:
Friends of Codorus State Park
1066 Blooming Grove Road
Hanover, PA 17331
Phone: 717-451-3635
Email: friendsofcodorus@gmail.com
Proceeds raised from this event will be used toward the betterment of Codorus State Park.

SIGN ME UP!!
FOOT PROTECTION IS REQUIRED TO PARTICIPATE
ALL MINOR PARTICIPANTS MUST BE ACCOMPANIED BY AN ADULT OVER 18 YEARS OF AGE

Name: _______________________________________________________

CHOOSE YOUR PLUNGE TIME

Address: ______________________________________________________

11 AM

Phone: ________________________ Email: _________________________

12 NOON

Signature: ____________________________ Date ____________________

1 PM

Registration Fee $35.00 Cash: ___________ Check #: _______________

**REGISTER BEFORE 12/25/2016 TO RECEIVE A FREE T-SHIRT OR CHICKEN PLUNGE HAT **


FOR REGISTRATIONS AFTER 12/25/2016: T-shirts will be available during the event for $10.00 per shirt.
(Please include payment for shirt with completed registration form.)
Size: _____Small ______Medium _____Large _____XL _____2XL _____3XL

OR

_______CHICKEN HAT

Access for People with Disabilities if accommodations are needed to participate in the Eagle Plunge Event please contact the Friends of Codorus at 717-451-3635
In consideration of participating in the Friends of Codorus State Parks Eagle Plunge, I represent that I understand the nature of the event, I represent that I am, and my minor
children participating are, qualified to participate, in good health, and in proper physical condition to participate in this event. IT IS STRONGLY ADVISED PARTICIPANTS
CONSULT THEIR PHYSICIAN BEFORE ATTEMPTING THIS EVENT and I acknowledge that I have been advised by the Friends of Codorus State Park to consult my
physician prior to participation. I acknowledge that if the event should be unsafe for me or my minor children, I will immediately discontinue participation. I understand there
may be risks involved such as serious bodily injury, including disability or death, which may be caused by my actions, actions of others, and/or conditions in which the event
takes place. I also understand there may be other risks not mentioned at this time. By entering the Eagle Plunge presented by the Friends of Codorus State Park, I understand
and agree to allow my image (and images of my minor children) to be used in materials to promote and/or advertise Codorus State Park. I (and my minor children) agree to hold
harmless the Friends of Codorus State Park and the Commonwealth of Pennsylvania representing Codorus State Park, and any/all persons acting under the authority to promote
the Eagle Plunge, from any and all claims, liability and discharge and covenant not to sue, which could arise by my participation in this event. I waive the right to inspect and/or
approve the finished product or advertising which may be used in connection to this event. I fully accept and assume all risks and responsibilities for losses, costs and damages
that I incur in connection to my (or my minor children) participation, in the event. I hereby release all claims, demands, losses or damages of any kind, whether sustained by me
or my minor children, whether caused in whole or part by the negligence of Releasees or otherwise, including negligent rescue operations. I further agree that if, despite this
release, waiver of liability and assumption of risk, anyone makes a claim against the Releasees on behalf of me or my minor children, I will indemnify, save and hold harmless
each of the Releasees from any loss, liability, damage or cost which may arise from such claim.

REGISTER AS A TEAM FOR THE EAGLE PLUNGE


$35.00 PER PERSON
Registration Opens 10AM
Eagle Plunge 11AM-1PM Winter Festival 10AM-2PM
Chicken Dance & Plunge 1PM (just take a few steps into the lake)

The team who raises the most money will receive a prize!
(Prize to be determined by the Eagle Plunge Committee)
**REGISTER BEFORE 12/25/2016 TO RECEIVE A FREE T-SHIRT OR CHICKEN PLUNGE HAT **
FOR REGISTRATIONS AFTER 12/25/2016: T-shirts will be available during the event for $10.00 per shirt.
(Please include payment for shirt with completed registration form.)
TEAM NAME

_____________________________________________________________________________________________________________________

TEAM LEADER

_____________________________________________________________________________________________________________________

NAME

ADDRESS

PHONE

TOTAL MONIES
RAISED

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

TOTAL COLLECTED

SIGNATURE