Registration Form
Print and mail to:
Lecanto High School, Med Share 5K
ATT: Freddie Bullock
3810 West Educational Path
Lecanto, Florida 34461
Please Cut Off and Return to:Med Share 5K, 3810 West Educational Path, Lecanto, Fl 34461
Make Checks Payable to: Lecanto High School Med Share /age on date of event
Name: __________________________________________________ Age: _____ M/F____
Address: (include zip) ____________________________________ Email Address: ________________
T Shirt Size (if received by Jan. 2, noon): XL____ L______ M________ S_____________
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 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: _______________________________