Chicken Plunger Graphic

2011 Polar Bear Plunge
"Freezin' for a Reason"
Online Chicken Registration Form

Team Name (if applicable):
Team Captain (if applicable):
Chicken Plunger Name
Email Address
Street Address
Street Address
City
State
Zipcode

Contact Person
Daytime Phone
Evening Phone

Gender Male Female
Age

Please note: Each plunger will receive either a Chicken T-Shirt or a Chicken Hat - please select below.

$20 minimum required

 Chicken Hat
Chicken T-Shirt -- T-shirt Size