Please type or print clearly, and mail (postmarked by Monday, September 14, 2009) the following 2nd Annual Push/Pull Powerlifting Championship meet registration form to Pinnacle Performance, P.O. Box 143, Charenton, LA 70523.

Name
Address
Phone
Email
Age	(you must be 18+ years of age to enter)
T-Shirt Size

Estimate your opening attempt, if applicable. Bench _______ Deadlift _______

Circle event. Bench Only (awards, no cash), Deadlift Only (awards, no cash), Push/Pull (to qualify for cash prizes)

Circle division. Unequipped (raw) or Equipped (up to 2-ply)

Please check one.

o I have enclosed a nonrefundable registration fee in the amount of $40, made payable to Pinnacle Performance, and remitted to P.O. Box 143, Charenton, LA 70523.

o A nonrefundable registration fee in the amount of $40 has been made via PayPal.

In consideration of the acceptance of this entry thereby for myself, my heirs, executors, and administrators waive and release any and all claims and damages I may have against Pinnacle Performance Physique and Strength Sport Enterprises, Inc., Fitness & Beyond Health Club, LLC, their representatives, successors, and assigns for any and all injuries or bodily harm that I may suffer while competing at the 2^nd Annual Push/Pull Powerlifting Championship. I attest and verify that I am at least 18 years of age, and I have full knowledge of the risks involved with my participation of this event.

Signature _________________________ Date _______________