What is your nerd name (Last, First, MI.)? 
                      Your e-mail address: 
            What is your real (hash) name? 
                   What is your home hash? 
                     What is your address? 
                                           
                    What city, state, zip? 
                      A real phone number? 

Disclaimer: I agree, that because I am defined as being a member of the human race, I am capable of self determination, and that, in determining what I myself might do, I will hold no other member of the human race responsible for any blatant acts of stupidity which may cause me grievous harm, including, but not limited to: running into trees, falling off logs, third degree burns from jumping naked over roaring fires, rashes caused by intimate social contact, poisoning or other sickness caused by excessive intake of alcohol, or bites from any animals, wild or domestic, which I may have baited with food or feigned kindness. Furthermore, I will refrain from any acts which may annoy our host, the landowner, or cause damage to his property. That I will also refrain from crude acts, sexual or brutish in nature, or unnatural thoughts that may cause emotional trauma to genteel ladies, if I can find any. Additionally, I will direct bodily secretions to appropriate receptacles, with the receptacle owners consent. And lastly, I ascent to being bodily removed from the premises, at gun point if necessary, should I fail to meet accepted standards of hash behavior.

Print the words in red near the bottom of the WEB INFO page: _______________

My legal signature: ___________________________

Keep a copy of this form so you can remember to NOT bring glass to Revolution!