NAME:______________________________________________   AGE:_________    SEX (Y/N)____________

HAT SIZE:_____________

ADDRESS:________________________________________________________________________________________________________

FAVORITE PARASITE:_____________________________________________

NEXT OF KIN:___________________________________

PREFERENCE FOR DISPOSITION OF REMAINS: _______________________________________________________________________

I can offer no reasonable explanation for even wanting to ATTEMPT the Barkley. But it is my own stupid idea. I realize that REAL challenges come with REAL hazards. I ACCEPT that NOTHING will be done to assure my safety and well-being. As a matter of fact, that is how I want it. I take full physical, financial, and emotional, responsibility for the outcome of my own Barkley run.

Signed:_________________________________________________________Date:_____________

Witness:_______________________________________________