Participant's Contact Information:
    Please Read All That is Below and Sign (type) Before Submitting. Thank You.

    Event Information and Waiver Release Form:

    Registration Fee:  $20 (Includes Free T-Shirt and Lunch)
    Date: Saturday, January 27th, 2017 
    Doors Open & Sign In: @ 11:00 am
    Contestants' Picture & Judging: 11:30am
    Parade to Waterfront: 11:45am
    Polar Dip: 12:00 pm
    Lunch to follow the Dip: Donation at the door to eat, please.
    Lunch and prizes will be in the Lynch Building (Dining Hall)
    Release and Waiver of Liability, Assumption of Risk and Indemnity, and Parental Consent Agreement

    To receive a commemorative long sleeve t-shirt, this form and $20 registration fee must be received by OOTB on or before January 16, 2017.
    Mail to:
    Occohannock on the Bay Camp,
    9403 Camp Lane,
    Belle Haven, VA 23306 

      In consideration of participating in the OOTB Polar Duck Dip Camp Benefit, I represent that I understand the nature of the event and that I and/or my minor child are qualified, in good health, and in proper physical condition to participate in this activity. In the case of a minor child's participation, the child's parent or legal guardian must be present at the event before it begins and until the minor child leaves the premises. I acknowledge that if I and/or my minor child believe the event's conditions are unsafe, I and/or minor child will immediately discontinue participation in the activities.

    I fully understand that the Polar Duck Dip event involves risks of serious bodily injury, including permanent disability, paralysis, and death, which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the "releases" named below; and that there may be other risks either not known to me or not readily foreseeable at this time, and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I and/or my minor child incur as a result of my and/or my child's participation in the activities.

    I hereby release, discharge, and covenant not to sue Occohannock on the Bay Camp and Retreat Center, or their respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and owners of the premises, Eastern Shore District of the United Methodist Churches (each considered one of the "releases" herein) from all liability, claims, demands, losses, or damages on my account and/or that of my minor child caused or alleged to be caused in whole or part by negligence of the "releases" or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver of liability, and assumption of risk, I or anyone on my and/or my minor child's behalf, makes claim against any of the "releases ", I will indemnify, save, and hold harmless each of the "releases" from any loss, liability, damage, or cost which any may incur as the result of each claim.

    I have read this Release and Waiver of Liability, Assumption of Risk and Indemnity, and Parental Consent Agreement, understand that I have given up substantial rights by signing it and signed it freely and without any inducement or assurance of any nature and intend it be a complete and unconditional release of all liability to the greatest extend allowed by law and agree that if any portion of this agreement is held to be invalid the balance notwithstanding, shall continue in full force and effect.

    I also understand and give permission to Occohannock on the Bay Camp and Retreat Center to take and use any video or pictures to help promote the camp through social media, newspapers, handouts, or camp fairs.

    I or my child(ren) will wear water shoes or other protective foot covering while plunging into to the Occohannock Creek.