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
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