Registration

REGISTRATION OPTIONS: 1. Online at flrunners.com; 2. You can register by returning the form below.

NO REFUNDS.

Deadline to enter is Wednesday, October 1, 7 p.m. Read registration carefully and fill in what is needed based on your registration needs—team or individual.

Please Print and Return to: Cross Country October 4, C/O Heather Wolfertz, Lecanto Middle School , 3800 West Educational Path, Lecanto, Florida 34461 Make Checks Payable to: LECANTO Middle SCHOOL

Team Name: ___________________________________ Coach: ___________________________

M F (circle which gender(s) you are entering.

EMAIL CLEARLY WRITTEN TO SEND A TEMPLATE TO ENTER YOUR ATHLETES, TEAM DEADLINE is Wednesday,

October 1, 7 p.m.: ___________________________________________________________________

Chip Agreement—required for all participants:

My signature confirms I understand I will receive an invoice for 20 dollars for any chip I fail to return if individual or for each member of a team if coach.

________________________________________________________ __________________

Print Name Date

________________________________________________________

Signature

(for teams, just sign below. All other information is for individuals)

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: __________________________________________________________________________________________

I understand that running/walking is a physical sport and injuries may occur. I release the organizers, sponsors, staff and administration of Lecanto Middle 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/Coach)Signature: ________________________________________________Date: __________________

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