Last Name_____________________________ First ___________________ Middle _______

Address ____________________________________________________________________

City _______________________ State ____ Zip __________ Phone ____________________

e-mail _________________________________________ Shirt size (XS, S, M, L, XL, XXL): ______

Date of Birth ____/____/_____ Age on 10/6/2012 (Minimum age 18)  ______  Gender _______

Previous Ultra Experience? _______________________________________ Anticipated AT100 finish time: _________

Is this your first 100-mile attempt? _____   Please list any previous years you completed the AT100 __________________

If applicable, please describe what kind of camping you will be doing at Lake Sylvia (RV, tent, etc.): __________________

List any medical conditions we should know of _______________________________________________________

Are you taking any prescription drugs?  Please list: ____________________________________________________

Please provide a contact (name and phone number) in case of an emergency ____________________________________

There will be a free spaghetti dinner Oct 5th for the runner and one guest. Please include $5.00 fee for each additional guest.

Entry limit:  150

Send application and entry fee (check payable to Arkansas Traveller 100) to: 

Chrissy Ferguson, 116 Turtle Creek Cove, Maumelle, AR  72113  

Registration fee is 100% refundable until July 1^st, 2/3 refundable until September 1; 1/3 until September 24.

For additional information, visit the Arkansas Traveller 100 website: http://www.runarkansas.com

e-mail: AT100@runarkansas.com or phone 501-472-9162

Race Waiver  -  PLEASE READ – This entry contains limitations of your legal rights.

I know that running an ultramarathon race is a potentially hazardous activity that could cause injury or death. I should not enter and run unless I am medically able and properly trained, and by my signature, I certify that I am medically able to perform this event, am in good health, and am properly trained. I agree to abide by any decision of a race official relative to any aspect of my participation in this event, including the right of any official to deny or suspend my participation for any reason whatsoever. I assume all risks associated with running in this event, including but not limited to: falls, contact with other participants, the effects of the weather, including high heat and/or humidity, traffic and the conditions of the road and trail, encounters with wild or domestic animals, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the race directors and workers, Arkansas Ultra Running Association, U.S. Forest Service, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event, event though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to race management to use any photographs, recordings, or other records of my participation in this event for any legitimate purpose.  I also understand that the race director has the right to refuse any entry, and that my registration fee is non-refundable after September 24, 2012.

Signature ______________________________________ Date ____________