Competition Team (Fee MUST accompany Entry Form to be valid- NO EXCEPTIONS- First 12 valid entries will be accepted)

Please read and complete this form carefully. Be sure to give all requested information.  Please type or print neatly.

Name of EMS Organization/Agency: ______________________________________________________

Address (Mailing):  _________________________________________________________________________________
                              #            Street                                                                  City                                             State                 Zip

Telephone:____________________ FAX: ____________________    Email(Captain)_________________________________
                                                                                                           Email (Team Member)________________________________
List the names and certification level of the team members below.   Once the team has checked in with registration upon
arrival, there will be no substitutions allowed. There will be no refunds given due to the nature of this event.  Registration
fees for each team in competition must accompany this entry form-NO EXCEPTIONS.  

Two - PERSON ALS TEAM  (At least one member of this team must be certified at the Paramedic level or be in school for

1.   Captain_____________________________________    Circle T-shirt Size   L   XL   XXL   XXXL

2.    ________________________________________     Circle T-shirt Size  L   XL   XXL  XXXL                                                           

Entry Fee:  $300.00 per Team (Includes 2 Awards Banquet Tickets and 2 Event T-shirts)

All Competition Team members should carefully read the following release, sign and date below.

I do for myself, my heirs, executors, administrators and assigns, hereby release and discharge Carolina Competition LLC
Committee Members/Chairman, Officials, Judges, Florence County EMS, The States of NC and SC, The host service and its
agents, employees, and committee members, and the owner(s) of any property or structures, and the cities, counties, or
jurisdictions, where The Carolina Competition is being held, from any and all liability, claims, suits of any kind or nature,
actions, causes of action, demands, or losses that may arise or result from any accident, event, or tragedy, during or in
connection with this competition in which I may be involved or associated.  I understand that there is always the chance for
unseen accidents and that I am competing and traveling at “my own risk” during this event.  I also consent to the use of my
name, video, or photograph, taken during the event, to be used now and in the future, for publicity and public relations in
promoting and advertising this event.  All participants are expected to respect other participants and all property.  The
above named groups and organizations are not responsible for acts caused by the willful misconduct or poor judgment of
any participant in this event.

_____________________________________________                  _______________
Signature                                                                                          Date

_____________________________________________                  _______________
Signature                                                                                           Date


_______ Tickets @ $30.00 each = $ ______________

****  Please note that 2 Banquet Tickets
are included in the Team Registration Fee  ****

TOTAL AMOUNT ENCLOSED $ __________  Make all checks payable to: Carolina Competition LLC

Mail forms to:         Carolina Competition LLC
                               517 Owen Drive
                               Fayetteville NC 28304