Statewide Plunge Athlete Ambassador Nomination Form Plunge Director Submitting Form(Required) First Last Athlete Name(Required) First Last Region(Required)ABCDEFGHIJKAgency(Required) Age of AthleteAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Please upload a photo of the athlete(Required)Max. file size: 29 MB.Athlete BioFor example: Sports they play, agencies they compete with, other hobbies or interests, etc.What sports are they involved in?(Required) Are they an Athlete Leader?(Required) Yes No Have they previously participated in video content with Special Olympics Illinois?(Required) Yes No Is the athlete nominee available to travel for filming?(Required) Yes No Is the athlete comfortable speaking in interviews, whether prerecorded or live?(Required) Yes No Has the athlete participated in the Polar Plunge in the past?(Required) Yes No Below, tell us why this athlete should be selected as our 2023 Polar Plunge Ambassador?(Required)We're wanting to engage more influencers this year. Please make 1-2 recommendations on local celebrities, media personalities, etc. from your region that M&C could reach out to. Add Remove*Use the + symbol to the right to add more names.
