Kansas Powerlifting Championships

   NASA Kansas State Entry Form Only - Late Fee's Begin 4-7-08

    First Name-    Last Name-

    Wt. Class-   Age-   DOB-     Phone-

   Address- City-

   State- Zip-        E-mail Address-

  Equipped Powerlifting Division(s) Entered (i.e. Pure, Open, M-1 etc)-,

Equipped Bench Only Division(s) Entered (i.e. Pure, Open, M-1 etc) -,

Unequipped Bench Press (wraps & belt only) - ,

Unequipped Powerlifting Divisions Entered- , ,

  Power Sports Full Meet Division(s) Entered (i.e. Pure, Open, M-1 etc) - ,

  Push Pull Divisions Entered (i.e. Pure, Open, M-1 etc)- ,

    Grand Total Number of Divisions Entering-

    Total to Charge this Card -$   Type of Credit Card-

    Credit Card Number               (example 1234-5678-9101-2344)

    Expiration Date of Credit Card Card - (example 06/23/03)

Comments or Questions-

Read this Waiver Completely Before Submitting - All Unsigned Entries Will Be Returned

In consideration of your acceptance of this entry, I hereby waive, for myself, my heirs and assigns, any and all claims for injury or damages which I may incur by virtue of my competing in this contest as against Rich Peters, NASA LLC Powerlifting, the facility used, Quality Inn and any of their agents and employees. I also realize that the sport of Powerlifting is a high risk sport and that I could be injured. I certify that I am in good physical health and have no serious health problems and that I assume full responsibility for such conditions. I also realize that I am fully responsible for my well being and safety in the warm up room, on the lifting platform and while I am lifting at this event. I also certify, by my signature, that I have read this waiver and fully understand and accept it’s terms. I also agree to submit to Urine Testing if I am selected by the meet director for such testing. I do hereby verify my acceptance of these terms by my agreement below. Do Not Agree to This Waiver Before Reading It Fully and Carefully. If you do not accept it’s terms, DO NOT sign it.

I agree to the terms of this waiver and do so indicate by my submission this Credit Card Entry.

I Realize that this Competition is an Anabolic Steroid Free Meet
I to the terms of this waiver (Initials)-

Lifting will begin at 10:00 am Saturday

114, 123, 132, 148, 165, 181, 198, 220, 242, 275, 308 & SHW

Women’s Weight Classes

Return Entry and Entry Fee’s

Entry Fee’s for Powerlifting, Push/Pull & Bench Press Only (equipment allowed)

$50.00 for first division entered, $35.00 for each additional entry. Late Fee after Deadline Date is $5.00 additional fee for 1st division entered. Cash Only for all late entries. All High School Entries are $40.00 and Late Fee's will be charged if entries are late.

“Power Sports" Entry Fee’s

“Power Sports” Raw, Totally Unequipped - Entry Fee’s

Power Sports INDIVIDUAL Events - Entry Fee - Awards in Each Individual Event Entered

Strict Curl Only= $50.00

Bench Only=$50.00

Deadlift Only= $50.00

Team Entry Fee

$35.00 per Team Entry. This fee is for the Team Trophy. Team Rosters MUST be turned in by the start of lifting on Saturday. Trophies for 1^st thru 3^rd for Powerlifting, Bench Press Only and Power Sports Teams. Maximum of 10 members per team.

I realize this Competition is an Anabolic Steroid Free Meet and I may be Tested by Urinalysis