Please type or print clearly, and mail (postmarked by December 22, 2008) the following 2nd annual APA Shut Up & Bench Press! 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

 

 

Circle weight class.

            Female             97, 105, 114, 123, 132, 148, 165, 181, 198, 220, Unlimited

            Male    114, 123, 132, 148, 165, 181, 198, 220, 242, 275, 308, 341, Super Heavy

 

Estimate your opening attempt, if applicable.  Bench _______

 

Circle category.  Men’s Open (nontested), Men’s Open (drug tested), Women’s Open (nontested), Women’s Open (drug tested)

 

Circle event. Bench Only

 

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

 

Circle affiliation. APA Member ($30/year; records will be recorded when you are a member), APA Nonmember (no added cost, but your record will not be noted)

 

Please check one.

 

o   I have enclosed a nonrefundable registration fee in the amount of $45, made payable to Pinnacle Performance, and remitted to P.O. Box 143, Charenton, LA 70523.

 

o   A nonrefundable registration fee in the amount of $45 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 the American Powerlifting Association, Pinnacle Performance Physique and Strength Sport Enterprises, Inc., Dynamic Health Club, their representatives, successors, and assigns for any and all injuries or bodily harm that I may suffer while competing at the 2nd Annual APA Shut Up & Bench Press! 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.  I understand, upon entering a drug tested division, there is random drug testing by urinalysis on a minimum of 10% of lifters.  APA policy bans a lifter for a period of 3 years if he or she tests positive for a banned substance.  Being unaware that a substance can cause a drug test failure is not an excuse.

 

Signature _________________________     Date _______________