Name: _________________________________________________________________________

Address: _______________________________________________________________________

City: ____________________________ State: ______________ Zip Code: _______________

E-mail: ________________________________________________________________________

T-shirt Size (circle one): YS YM YL S M L XL XXL

Do you have a preference for a specific volunteer activity? (please list) __________________________

Note: All Volunteers must fill out this form. If you would like a separate Volunteer T-shirt the cost will be $10

which must be paid before May 21, 2010. If you are registered for the event and would only like a

Volunteer T-shirt and not a Participant T-shirt please indicate below.

I would like to purchase a Volunteer T-shirt. (Include $10 with this registration form)

I am registered for the event and would like my Volunteer T-shirt to replace my Participant T-shirt.

(No additional cost)

I understand that partcipating/volunteering in an event like this is a potentially dangerous activity. By registering as a

volunteer for this event I am asserting that I am medically able to participate/volunteer; I am primarily responsible for my

own safety. I acknowledge and accept the potential risks associated with this event, including, but not limited to, falls, road

conditions, weather (extreme heat or cold, rain), and traffic. Taking all of the things into consideration, I, for myself and

anyone entitled to act on my behalf, waive and release Archer Lodge Volunteer Fire Department, the Archer Lodge

Community, Johnston County employees, race staff and volunteers, and all agents, officers, sponsors, their representatives

and successors from all claims or liabilities that may arise from my participation in this event. I also give my full permission for

photographs and/or video of myself and dependants to be used in legitimate accounts of this event.

Signature:

_______________________________________________________________________________________________________________

Parent/Gaurdian Signature if under age 18:

________________________________________________________________________________________________________________

Date:

________________________________________

Mail Entry to:

Archer Lodge Volunteer Fire Department