2012 Penguin Plunge

INCENTIVE ORDER FORM

Please complete the form below to redeem your prize by FEBRUARY 20, 2012

Plunge Participant Information

Name:

Team Name:

Address:

City:

State:

Zip:

Phone:

E-Mail:

Incentives

Choose one item below based on actual funds raised:

Select only one level

 

Goosebumps Level - $100 / $50 for plungers under 16

  Official Long-Sleeve Plunge T-Shirt (select if you DID NOT receive your shirt at the plunge)

 

 

Cold Level - $500

  Beanie (& Plunge shirt)

 

 

Frostbite Level - $1,000

  Duffel (& Plunge shirt)

 

 

Frigid Level - $1,500

  iPod Shuffle (& Plunge shirt)

OR

  Vest (& Plunge shirt)

 

 

Arctic Level - $2,500

  iPod Nano (& Plunge shirt)

OR

Jacket (& Plunge 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.  We will contact you via email when your incentive is available for pick up.

      

Thank your for supporting Special Olympics Montana athletes!