WAIVER AND RELEASE: In participating in the Dallas Elks #71

3rd Annual “3rd Dip” Polar Bear Dip, I understand the nature of the event and that I and/or my minor child am in good health and proper physical condition to participate in such an activity. I understand that the Polar Bear Plunge event involves risks, primarily of getting cold, but also the possibility of injury or death; and I fully accept and assume all such risks I and/or my minor child incur as a result of participation in this activity. I hereby release, discharge, and covenant not to sue the Dallas Elks #71, from all liability, claims, demands, losses, or damages. I have read this RELEASE AND WAIVER OF LIABILITY, and have signed it freely. I also authorize the Dallas Elks #71 to have and use photographs or video of the child named on this form as may be needed for Dallas Elks #71 archives or Public Relations.



Participant Name and Address (Please Print)



Participant Signature/ or Parent Guardian Signature (if under the age of 18) Date___________


Return Pledge Form and Waiver prior Event by mail or email to:


Dallas Elks #71

8550 Lullwater Dr.
Dallas, TX 75238-4753 ; by email: elks71polardip@gmail.com or contact Steve Conway at 214-762-0031 with any questions  812/2016