APPALACHIAN POWERLIFTING
Please read and complete entry form and Waiver at the bottom.
YOU MUST PRINT and mail entry form and waiver with your payment to
Derek Wingo
box 115
Warriormine, WV 24894
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Entry Form
This form is for all events, just write in the name of the competition you are entering
and than check everything that pertains to you and the event. Be sure to know which
events are offered at the competition before filling out this form and only enter events that are offered at each competition.
Name of Contest: ________________________________________________ Date:_______
Print Full Name: ____________________________________ Age:____
Date of Birth:____________
Address: ______________________________ City:____________________
State: _______ Zip: _______
Phone No: _____________________________
Email: ___________________________________________
Parent or Guardian must sign for you to lift if you are under 18. Also fill out a weaver and mail with your entry form.
Parent or Guardian signature:____________________________________________________
Select the Events pertaining to the Contest you are entering:
YOU MUST CHECK ONE
NOTICE: ONLY SELECT THE ONES THAT PERTAIN TO THE EVENTS YOU ARE ENTERING.
Multi Ply- Full Powerlifting:____ Raw Full Powerlifting..................____
Single Ply Powerlifting..... ____ Raw Bench Press Repetitions.._____Multi-Ply- Push / Pull......____ Raw Push / Pull.......................____
Multi-Ply- Squat Only.....____ Raw Squat Only ....................._____
Multi-Ply- Bench Press.... ____ Raw Bench Press................... ____
Multi-Ply- Deadlift..........____ Raw Deadlift..........................____
Strict Curl Competition....____
You can enter more than one event if you would like, just check the events you want
to enter. And send the appropriate fees according to the contest you are entering.
What Divisions are you entering?
Teenage: _____ Junior(20-23)_____ Women_____ Men _____ Sub-masters(33-39)___ Masters(40-44) ___ Masters(45-49)___Masters(50-54)___Masters(55-59)___
Masters(60-64)___ Masters(65-69)___
Other ________
What Weight Class are you entering? If you don't make weight, you go to the one
you do make.
Wt. Class: 114___123___132___148___165___181___198___220___
242___259___275___308___Super Heavy___
Entry Fees: Send the amount as advertised for each event on upcoming meet page.
All APPLICATIONS and FEES must be mailed to Derek Wingo, box 115,Warriormine, WV. 24894
Make all Checks payable to Derek Wingo.
APPALACHIAN POWERLIFTING WAIVER
Release, Waiver of Liability, Assumption of Risk, Indemnity, and parental Consent Agreement
In consideration of being permitted to participate in a APL activity. I, my personal representatives, assigned heirs and next to kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of the activity and that I am qualified, in good health and in proper physical condition to participate in such activity. I further agree and warrant that if at any time I believe conditions to be unsafe; I will immediately discontinue further participation in the activity.
2. FULLY UNDERSTAND that: (a) ATHLETIC ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH (b) these Risks and dangers may be caused by my own actions or the actions of others participating in the activity, the condition in which the activity takes place, or THE NEGLIGENCE OF THE NAMED BELOW: there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time: and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the activity.
3. I HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the APL, as well as the officers, directors, agents, employees and assigns of each, and the APL, clubs, coaches, officials, administrators, members, volunteers, participants, sponsors, advertisers, and if applicable, owners and lessors of premises on which the activity takes place, and any other party indemnified and held harmless by the APL, (each considered one of the here in) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, NEGLIGENT SECURITY, TRAVEL, AND RECREATIONAL OPERATIONS AND ACTIVITIES; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the RELEASE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASES from any litigation expense, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.
4. I am to be solely held responsible for any damages I may cause willingly or by accident to the property of the APL or the Property in which the weight lifting tournament is held. I will pay in full personally, for any damages that may occur on my behalf, directly to the APL or to the Place in which the Tournament is held. I agree that the APL is not responsible for my actions, only I and I alone am responsible for any debts that may occur.
I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOT WITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Printed name of participant: _______________________________________________
Date :_____________
Participant signature (only if age 18 or over):__________________________________________________
Minor RELEASE
AND I, THE MINORS PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF ATHLETIC ACTIVITIES AND THE MINORS EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINORS ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASE OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE. I THE MINOR OR ANYONE ON THE MINORS BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASES NAME ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
Printed name of parent or Guardian:__________________________________________________________________
Date:_________
Parent/Guardian: ___________________________________________________ Date:____________