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2. THE GREAT PUMPKIN PLUNGE REGISTRATION

   Jacksonville Community Center | October 28, 2024 | 6:30pm | Check-in @ 5:00pm

4. Name:*
5. Phone #:*
7. Address1*
9. City*
10. State*
11. Zip*
13. Age Group:*
    -- Select One --3&4 (adult must be in pool with child)5&67&89&1011&12

    ALL 3-4 yr olds are REQUIRED to have a parent/guardian in the water with them. There is a $3.00 fee for the parent/guardian.

14. Participant can swim unassisted?*

    1. Yes
    2. No*

    $3.00 fee for parents in water with non-swimmers.

15. Non-swimmers must either bring a US Coast Guard approved life vest to the event and a parent must be in the water with them during the pumpkin plunge. Due to limited space, a $3.00 parent fee will be charged at the time of registration. Water wings will NOT be permitted.

17. Fees:

    Parent: $3.00 
    (ALL 3-4 yr olds & non-swimmers with a parent/guardian in the water).

    Child: $5.00

18. For Office Use:

    Total Received: _________________________

    Cash / Check #: _________________________

    
    

20. SWIMWEAR REQUIRED:*

    1. Yes

    I understand a swimsuit is required to be worn by the participant and the parent/guardian that get in the water.

22. Participant Liability Waiver:

    I, ______________________________________ (Parent/Guardian of Minor) do hereby acknowledge the release and discharge of all actions, rights, causes of action, claims, and demands whatsoever that now exist or may hereafter accrue against the City of Jacksonville Parks and Recreation Department, and any other person, corporation, association, or partnership charged or who which may be charged with responsibility for injury and/or damage to the person and property of the undersigned , the treatment thereof, and all consequences flowing there as participation in the Great Pumpkin Plunge sponsored by the Jacksonville Parks and Recreation Department.

    I warrant that no promise or inducement has been offered for execution of the document and accept full responsibility for participation in the Great Pumpkin Plunge, that I am of legal age, am competent to execute this release, accept full responsibility for the execution thereof and recognize potential for danger resulting from involvement in such an activity.

    I further agree that this Release shall apply to all known, unknown, and unanticipated injuries and/or damages resulting from participation in the Great Pumpkin Plunge and will remain in effect for the duration of the event.

24. Agreement:

    I hereby consent to the use, reproduction, editing and/or broadcast by the City of Jacksonville, AR of any and all photographs, video recordings and audio recordings of me and/or my family, taken by or on behalf of the Jacksonville Parks and Recreation department, without any compensation to me. All negatives and positives prints video-recorded images and audio recordings shall constitute the property of the City of Jacksonville solely & completely. Please print your name below.

26. Payment:

    Registration is complete once payment is received. Once you submit the Registration form you will be directed to pay online. 

    If you choose not to pay online at this time, you can click on the link below at a later date or pay in person at the front desk of the Jacksonville Community Center. 

    https://secure.rec1.com/AR/jacksonville-ar/catalog?filter=c2VhcmNoPTI3MDMyODY=

28. Parent/Guardian:*
29. Date:*
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field