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Pound Plunge Program Registration Form
Please fill out the form below:
  • Please make sure you have entered a valid email address in order for you to receive your team's number and information.
  • Please check all your information that you had entered are correct before you click Submit.
  • Once you click Submit, do not re-submit. Each participant is only allowed on one team only, not on multiple teams. Any duplicate entries will be deleted from the system.
  • An email confirmation will be sent to you within minutes.
  • Up to date information about Pound Plunge Program will be posted at www.PoundPlungeSalina.com
Team Name: *  
 
Team Captain Address:
Address: *  
Captain Phone: *   ex: 111-111-1111      
Captain Email: *  
Team Captain: *(All fields are mandatory)
Name: Gender: Age: T-shirt Sizes:
Blood Works:
  
Team Mate 2: *(All fields except email are mandatory)
Name: Gender: Age: T-shirt Sizes:
Blood Works:
  
Phone: ex: 111-111-1111 Email:
Team Mate 3: * (All fields except email are mandatory)
Name: Gender: Age: T-shirt Sizes:
Blood Works:
  
Phone: ex: 111-111-1111 Email:
Team Mate 4: * (All fields except Email are mandatory)
Name: Gender: Age: T-shirt Sizes:
Blood Works:
  
Phone: ex: 111-111-1111 Email:
Pound Plunge Salina Program Rules and Waiver agreement:

PLEASE READ CAREFULLY!

THIS IS A LEGAL DOCUMENT WHICH AFFECTS YOUR LEGAL RIGHTS!
WAIVER AND REALEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT. 

I, the participant, in consideration of being permitted to participate in the POUND PLUNGE SALINA Program (“the Program”), state and agree as follows on behalf of myself and my personal representatives, next of kin, heirs, executors, administrators, agents, and assigns:

1.        I agree to each of the program rules listed on the website of PoundPlungeSalina.com: http://www.poundplungesalina.com/Rules.aspx. I understand I may be disqualified from the Program if I fail to adhere to any Program Rule. 

2.         I understand that any weight loss program (including, but not limited to, change in diet and physical exercise or activity) involves the risk of bodily illness or injury, including permanent disability, paralysis, and death.  I understand that such injury may be caused by my own actions or inactions, or the actions or inactions of others. 

3.         I agree to participate in the Program at my own risk.  This includes, but is not limited to the following: (a) any changes in my dietary intake; (b) any physical activity in which I engage; (c) my participation in any event relation to the Program, regardless of the location of such event; and (d) my use of any information, instruction, advice, example, direction or suggestion I receive through or in connection with the Program.  I agree that I am voluntarily engaging in he Program and all related actives.  I assume all risk of injury, illness, damage, or loss of any kind resulting from my participation in the Program and all related activities. 

4.         I agree to release and discharge Salina Family YMCA, COMCARE, Salina Regional Hospital, Salina Parks and Recreation, WorldLinc Corporation, Eagle Communications, Inc. and any other sponsors of the Program (and their Affiliates, employees, agents, representatives successors, and assigns) (collectively referred to herein as “Sponsors”), to the fullest extent permitted by law, from any and all claims or causes of action (know or unknown) arising out of negligence on part of any Sponsor(s).  If, despite this agreement I, or anyone on my behalf makes a claim against any Sponsor(s), I will indemnify, save and hold harmless such Sponsors(s) from any litigation expense, attorney fees, loss, liability, damage or cost such Sponsor(s) may incur as a result of such claim.        

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS.  I HAVE HAD AN OPPORTUNITY TO ASK ANY QUESTIONS I MAY HAVE CONCERNING THIS AGREEMENT, AND UNDERSTAND ALL SUCH QUESTIONS HAVE BEEN ANWSERED TO MY SATISFACTION.  I UNDERSTAND THAT THIS AGREEMENT CANNOT BE MODIFIED ORALLY. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT. I HAVE SIGNED THIS AGREEMENT FREELY AND WITHOUT ANY INDUCMENT OR ASSURANCE OF ANY NATURE. I INTEND THIS AGREEMENT TO BE THE FULLEST EXTENT ALLOWED BY LAW. I agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.