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Plunge for Elodie – South Beach, Staten Island NY
March 7, 2020

PARTICIPANT WAIVER

*PLEASE PRINT AND BRING WITH YOU ON PLUNGE DAY MARCH 7, 2020*

In consideration of being permitted to take the Plunge for Elodie at South Beach, Staten Island, NY for the purpose of fundraising, (the “Activities”) I acknowledge and agree to, on my own behalf, and on behalf of my personal representatives, heirs, assigns, executors, administrators and next of kin, as follows:

1. I am aware and acknowledge that injury or death may result from the Activities and/or from the presence at or use of the premises of South Beach, Staten Island part of the NYC Parks Department (the “Premises”).

2. Upon entering the Premises, I will inspect the same and my observation and use of said Premises shall constitute an acknowledgement that I find and accept them to be safe and reasonably suited for their intended purpose.

3. I hereby release the Plunge for Elodie, the EB Research Partnership, Inc. (EBRP), and The NYC Parks Department, and their respective members, directors, officers, shareholders, employees, property managers, agents, contractors and their successors and assigns (collectively the “Releasees”), from any and all costs and liability for any loss, damage, injury, expense, demand, or cause of action that I may suffer whether with respect to any personal injury, death, damage to or destruction of property, theft or otherwise which is related to my presence in, upon or about the Premises as a consequence of my presence on the Premises and/or the Activities.

4. I will indemnify and hold harmless the Releasees, collectively and individually, from any and all losses, liabilities, damages, demands, costs and expenses that they may incur, for any reason whatsoever, which may arise as a result of my participation in the Activities and my presence in, upon or about the Premises.
I acknowledge that I have read this Waiver of Liability and have received the opportunity to discuss this with my legal counsel. Further, I acknowledge that I fully understand the terms of this Waiver of Liability and that I have signed it freely and voluntarily without any inducement, assurance, guarantee or oral representation being made.

*By signing this waiver, I also agree to allow the Plunge for Elodie to take photographs and video content during the event that may include my likeness. Any photo/video content taken at the event may potentially be used on Plunge for Elodie social media channels or in future Plunge for Elodie promotional materials.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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