APC National Powerlifting Championship
July 9, 10, 2016
Jefferson civic Center
65 Kissam Street
Jefferson,
Ga. 30549
Name____________________________________________________________
Address__________________________________________________________
City _______________________State__________Zip______________________
Phone________________________________ Birth date____________________
Email____________________________________________________________
Check all appropriate categories in each column below:
Raw___
Equipped____
__Powerlifting Meet
---Deadlift Meet |
___Open
Teenage:
___Sub-master 35-39 |
Master:
____40-44 |
Weight Class: Women:
__44Kg |
|
|
Release from Liability, Read this
carefully: By signing this you will be giving up important rights, in
consideration of my acceptance of my entry form in this powerlifting
competition, I understand that I am legally bound for not only myself but also
for my heirs, my executors, and my administrators in signing this release form
liability I waive and release Anthony Williamson, James Houston, Marcell Allen,
Stephanie L Williams, IRON BEAST GYM, American Powerlifting Committiee, Inc. and
all Officers. All Officials, Referees, Spotter/Loaders and any other
persons or firm taking part in this competition from any and all liability which
may arise from this competition, I understand all of the above for my acceptance
of my entry in this competition, By signing this entry form I affirm that all
the information on this form is correct
Signature________________________________________________________
APC Card Number_______________
Parent or guardian if under 18________________________________________
Powerlifting $100.00----Pushpull $90.00---- Bench $80.00--- Deadlift $80.00
Send check and entry form to Anthony Williamson 1610 Oconee Point Jefferson Ga 30549