Mail In Registration CASA

Please Print and Return to: Colors for Casa 5K, C/O Freddie Bullock, Lecanto High School , 3810 West Educational Path, Lecanto, Florida 34461

Make Checks Payable to: LECANTO HIGH SCHOOL /age on date of race

Name: _________________________________________________ Grade: _____ Age: _____ M/F____

Address: (include zip) ___________________________________Email Address: ________________

Parent/Guardian: (if under 18 day of event)_________________________Phone: H ____________ W____________

Emergency Contact: _________________________________________ Phone: ___________

Insurance Company: _______________________________________ Policy #: _______________

Allergies or medical conditions: ________________________________________________________________________

Shirt Size: Adult XS ____ Adult S___ Adult M___Adult L___Adult XL___ Adult XXL(2 dollars more)___

Additional Shirt sizes:____________________________

I understand that running/walking is a physical sport and injuries may occur. I release the club organizers, sponsors, staff and administration of Lecanto High School, the Citrus County School Board, the employees or sub contractors from David D Bullock, LLC from any legal responsibilities for any possible injury or consequences that may occur. I also authorize the meet director/club sponsor of the event to act on my behalf if an injury occur and I cannot answer responsibly. I understand if my child under the age of 18 is participating, the same procedures apply to my child.

(Parent)Signature: _________________________________________________________________ Date: _________

Date received: _____________________ Payment Type: Check #_____________________ Cash: ____________________ Received by: _________