U.S.A Powerlifting
Rockview Powerlifting
"ICEBREAKER BASH 2003"
January 18th, 2003

NO ENTRY FEE!! LIFTERS WILL BE GIVEN GAS MONEY!! LUNCHES PROVIDED!!!

EVERYONE, INCLUDING COACHES MUST COMPLETE THE TOP OF THIS FORM!!

Entry Deadline December 27th, 2002

Restrictions
Nobody under the age of 18
No female lifters.
Sorry this is prison policy not the USAPL!

PLEASE COMPLETE ALL INFORMATION THAT APPLIES TO YOU, SO YOU CAN BE CLEARED TO LIFT BY THE INSTITUTION. THANK YOU.
Name: _______________________ ________________ ____
(Last Name) (First Name) M. I.

Age:_______  Date of Birth:____/____/_____ 

Weight class:________   Driver Lic # State_______ & #__________

Social Security #__________________________

USAPL Card # ________

Address: Street________________________ 

City:________________________________ 

State: _________ Zip:_______________ 

Home Phone: (____)-_____-___________ 

Work Phone: (____)-_____-___________ 

E-mail:_____________________ 

Fax #: (_____)-______-_________

 
 ***ATTN: DO YOU PLAN TO BE A LIFTER : __________ COACH: _________
OTHER: _______***

SIGNATURE:_____________________________________


***Only lifters must complete the Release From Liability section of the form***

RELEASE FROM LIABILITY
(Read this carefully) In consideration of the acceptance of my entry form in this powerlifting competition I intend to be legally bound, for not only myself but also for my heirs, my executors and my administrators. In signing this release from liability I waive and release everyone connected with this competition from any and all liability, including any result of negligence, which may arise from this competition. Moreover, I agree that any testing method which the meet director and the sponsors of this meet use to detect the presence of strength inducing drugs SHALL BE CONCLUSIVE. This is, whether I think the results of the test are right or wrong, I agree that I have no right to challenge the results of the drug tests. I further agree to submit to any physical test, which may be necessary to complete the drug testing. Should I fail to pass the drug tests I agree to forfeit any trophy or award, which I might otherwise have won. I understand and agree that if I fail to pass the drug tests, my name will appear on a published list of suspended members. f it is determined that I have failed the drug test, I agree to waive any claim for which legal relief is available. I agree to pay any attorney fee and litigation expenses by any person, real or corporate, whom I may sue in an effort to challenge this release from liability form. I understand that my agreement to pay attorney fees and litigation expenses is the SINE QUA NON for acceptance of my entry in this contest. If any provision of this Release from Liability shall be deemed by a court of competent jurisdiction to be invalid, the remainder of this Release from Liability shall remain in force and effect. I also certify with my signature that this release/agreement cannot be modified orally. 
 

_____________________________ 
Lifters Signature                        (date)
Mail Entry Tom Peterman
SCI Rockview
Box A1, Rt 26
Bellefonte, PA 16823