ENTRY FORM
UAPC NATIONAL CHAMPIONSHIPS
UAPC/APC STATE CHAMPIONSHIPS
Where---QUALITY INN I57&RT50
8OO North Kinzie Ave.
Bradly Il 60915
When---Saturday April 15, 2006
Session 1------UAPC
Session 2------APC
Weigh ins-Friday April 14th---9am to 1pm
4pm to 8pm
Late weigh ins - Saturday April 15--7:30-8:30am
NAME_______________________________________ADDRESS_____________________________
CITY___________________________STATE__________ZIP__________________
PHONE_______________________BIRTH DATE________________AGE_______________________
WEIGHT CLASS (circle one)
Men--52k 56k 60k 75k 82.5k 90k 100k 110k 125k 140k 140+k
Women--44k 48k 52k 56k 60k 67.5k 75k 82.5k 90+k
DIVISION (circle all that apply) UAPC STATE APC STATE UAPC NATIONAL
Open Teenage 13-19 Master: 40-45 45-49 50-59 60-64 65-69 70-74 75-79 80
LIFTING CATEGORY and FEE (circle one)
Powerlift only $50 Bench only $50 Powerlift/bench $80 $30 extra for each Division
Send entry form and fee to: JAMES ROUSE 100 KEUKA STREET JOLIET, IL 60436
Entry deadline: March 30, 2006 ($10 extra fee on all late entries) after March 30, 2006
Release from Liability: PLEASE READ CAREFULLY:
By signing this, you will be giving up important rights. In consideration of acceptance of my entry form
for 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 from liability I waive and release, Brandon Williamson and James Rouse, the UAPC, APC, Quality Inn and staff, all officials, referees, spotters and loaders and any other person or firm taking part in this competition from any and all lialility which may arise from this competition. I undersstand all of the above for my acceptance of entry in this competition. By signing this entry form, I affirm that all the information on this form is correct.
SIGNATURE DATE
Parent or guardian if under 18