Please Print and Mail or Drop Off to: The Resolution 5K, C/O Nelson Plasencia, Fellowship Church, 16916 NW US HWY 441, High Springs, Florida 32643
Make Checks Payable to: Fellowship Church /age on date of race
Name: _______________________________________________________ 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 S ___ Adult M___ Adult L___ Adult XL___
I understand that running/walking is a physical sport and injuries may occur. I release the club organizers, sponsors, staff and administration of Fellowship Church, the Alachua Government for use of facilities, Alachua County, the employees or sub contractors from Athletics Scoring Providers 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: _________