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
_________________________________________