Fall 2023 Cross Country Registration Form
Fall 2023 Cross Country Registration Form
For details,
visit our website
or email Peter Jensen at
pjensen@lcmcs.org
.
Student Information
Student's Name:
Student's Name:
*
First
Last
Classroom:
*
MAC
Oregon Trail
Mahonia
Redwood
Prairie Dog Home
Columbia
Celilo Falls
Willow
Sea Otter
Age:
*
Birthdate:
Birthdate:
*
/
MM
/
DD
YYYY
Parent Information
Parent's Name:
Parent's Name:
*
First
Last
Parent's Email:
*
Cell Phone:
Cell Phone:
-
###
-
###
####
Work Phone:
Work Phone:
-
###
-
###
####
Other Phone:
Other Phone:
-
###
-
###
####
Mailing Address
Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal / Zip Code
Country
United States
Emergency Contact & Pickup Information
Emergency Contact:
Emergency Contact:
*
First
Last
Emergency Contact Phone:
Emergency Contact Phone:
*
-
###
-
###
####
Names of the individuals authorized to pickup student:
*
Payment Information
Checkboxes
*
Checkboxes
I understand that a $130 participation fee is due upon registration. You will be directed to a payment page upon submission of this form.
$
0
Total