End-to-End Registration Form

Please include a $30.00 registration fee.  This fee is non-refundable after March 31, 2012. Checks should be made payable to the Taconic Hiking Club and mailed to Pam Bailey, 39 Fane Court, Troy, NY 12182.

Completed registration forms will not be accepted until January 1, 2012. There will be a ceiling of 25 entrants for this event, with each application handled on a first received, first served basis. Additional entrants will be placed on a waiting list in case of cancellations. All applicants must be 18 years or older.

I, the undersigned, declare myself physically fit and able to participate in the above event.  I realize that hiking events such as this are physically strenuous and hereby agree to be solely responsible for my own safety during this 29-mile hike.

I also acknowledge, agree and release the Taconic Hiking Club and any and all of its volunteers from any and all liability claims, losses and/or damages for personal injuries or death which may occur while participating in this event.

Name_________________________________

Date______________________

Address_______________________________

            _______________________________

Phone _______________________________

E- mail_______________________________

Emergency Contact Name & Phone________________________________

Signature______________________________

Name and address of hometown newspaper for press release after the challenge

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