2011 Great Falls Polar Bear Plunge

INCENTIVE ORDER FORM

Please complete the form below to redeem your prize by DECEMBER 17, 2011

Plunge Participant Information

Name:

Team Name:

Address:

City:

State:

Zip:

Phone:

E-Mail:

I have earned the following incentive level:

Please select your item below.  All plungers will receive incentives based on actual funds raised.  You will be contacted via email when your incentives are available for pick up.

Goosebumps Level - $100

  Official Plunge Long-Sleeve Shirt (select if you did not receive your shirt at the plunge)

 

Chilly Level - $250

  Beanie & long-sleeve shirt

 

Cold Level - $500

  Towel, Beanie & long-sleeve shirt

 

Frostbite Level - $1,000

  Duffel, Towel, Beanie & long-sleeve shirt

 

Frigid Level - $1,500

  Vest, Duffel, Towel, Beanie & long-sleeve shirt

 

Arctic Level - $2,500

  Jacket, Vest, Duffel, Towel, Beanie & long-sleeve shirt

 

Totally Chilled Out

  To further support Special Olympics Montana, I decline the incentive prize for which I qualify (optional).

 

Please verify information is correct before submitting

      

Thank your for supporting Special Olympics Montana athletes!