Registration

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

Name: _________________________________________________Grade: _____ Age: _____ M/F____

Division: Elementay PreK-2^nd______ Elementary 3^rd-5^th _____ Middle _____ High ______ Adult_________

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 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: __________________________________