Registration form

Please Print and Return to: Arrowhead 5K, Fort White High School Att: Scarlet Frisina, , 17828 Hwy 47, Fort White, Fl 32038 Make Checks Payable to: Fort White High School Cross Country /age on date of event

Name: __________________________________________________ Age: _____ M/F____

Address: (include zip) ____________________________________ Email Address: ________________

T Shirt Size (if received by Jan. 2, noon):XXL____ XL____ L_____M______ S______ Youth Sm____ Youth Med___ Youth L___

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 Fort White High School, the Columbia County School Board,Columbia County Board of Commissioners, Alligator Lake Park and its employees, all volunteers, the employees or IC for timing 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: _________