2022 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:
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 Postal / Zip Code Country
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 $125 participation fee is due upon registration. You will be directed to a payment page upon submission of this form.
$0

Total