Please type or print clearly, and mail (postmarked by Monday, February 15, 2010) the following 3rd Annual 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. Men 114, 123, 132, 148, 165, 181, 198, 220, 242, 275, 275+

                                Women Lightweight <148, Heavyweight 165+

 

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

 

Estimate your opening bench press attempt.  __________

 

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 on or before the date of February 15, 2010.

 

o        A nonrefundable registration fee in the amount of $40 has been made via PayPal at pinnacleperformance.biz/3rdannualshutupandbench.html on or before the date of February 15, 2010.

 

o        After February 15, 2010 until the day of the event, I have enclosed a nonrefundable registration fee in the amount of $55 (which includes an additional $15 for late registration), made payable to Pinnacle Performance, and remitted to P.O. Box 143, Charenton, LA 70523.

 

o        After February 15, 2010 until the day of the event, a nonrefundable registration fee in the amount of $55 (which includes an additional $15 for late registration) has been made via PayPal at pinnacleperformance.biz/3rdannualshutupandbench.html.

 

In consideration of my acceptance of this registration application and my participation in the 3rd Annual Shut Up & Bench Press! Championship, I waive and release any and all claims and damages that I, my legal counsel, heirs, executors, or administrators may have against Pinnacle Performance Physique and Strength Sport Enterprises, Inc., Jim Phelps, Fitness and Beyond Health Club, and their representatives for any and all injuries or bodily harm that I may suffer while competing in the above competition.  I attest and verify that I am at least 18 years of age, and I have full knowledge of the high risks of injury involved with my participation in the events associated with the competition. 

 

Signature _________________________     Date _______________

 

“I can do everything through Christ who gives me strength.” - Philippians 4:13