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: _______________________________