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Panhandle Domination Registration Form

March 11, 2017

 

Last Name: ____________________     First Name: ____________________     Middle Initial: _________

 

Address: __________________________________City/State: ______________________________ Zip: ___________

 

Home Phone: (      ) ____-_______ Cell Phone:(     ) ____-______              Email:_____________________________

 

Date of Birth:_____/______/______   

 

Wt. Class Lbs. (Men): 114 123 132 148 165 181 198 220 242 275 308 SHW (circle one)   

 

Wt. Class Lbs. (Women):     97 105 114 123 132 148 165 181 198 220+(circle one)   

 

Division/Age Group:    Teen (13-15) Teen (16-17) Teen (18-19) Open Junior (20-23) Sub-master (35-39)

Masters: (40-44) (45-49) (50-54) (55-59) (60-64) (65-69) (70-74) (75-79) (80-84) (circle one)        

 

Push/Pull  _____Bench-only _____Dead lift-only  _____RAW  ______UPA  _____UPAA (Drug Free)   

 

 

Push/Pull Entry Fee: $40

BENCH ONLY / DEADLIFT ONLY - $35

Additional Divisions Entry Fee - $15

Make check money order payable to: Chipola College TRiO Society

3094 Indian Circle (A-120), Marianna, Florida 32446

 

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APC Membership card - $30   APC Teen Membership card - $15 (can be purchased at the time of weigh-ins)

 

LIFTER MUST HAVE A VALID APC CARD TO QUALIFY TO SET FLORIDA STATE AND NATIONAL RECORDS

 

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ALL COMPETITORS MUST R.S.V.P. TO: davidcobb1124@yahoo.com  ASAP with their name, address, phone number, weight class, division/age group, and whether they’re push/pull meet, bench­only, deadlift­only, or competing in additional division.    

 

Note:   Each athlete MUST show his/her APC membership card at weigh-in. If he/she cannot, then they will have to buy one and their membership will be extended a year.    

 

Waiver:   In consideration of the acceptance of this entry, I hereby for myself, my heirs, executors, administrators, David Cobb, Chipola College, Chipola College TRiO Society, staff and student, FitScript Fitness of any affiliation waive and release any and all rights and claims for damages I may have against the APC, their representatives, successors, and assigns for any and all injuries or bodily harm that I might suffer while competing at the Panhandle Domination Meet on March 11, 2017.     

 

Signature of Competitor: ____________________________________

or Parent/Legal Guardian if Competitor is under 18 years of age

_________________________________________ 

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