DATE October 25th 2015
VENUE: Jim’s Gym/CrossFit607
ENTRY FEES: $25 for open, $20 for youth, Entries must be postmarked by October 19th ($10 additional late entry fee)
Fee must accompany entries – Payable to : Jim’s Gym
Mail to: Jim Wheaton , 828 Erie St, Elmira NY 14904
Email Questions to : CrossFit607@gmail.com
Call with Questions to: 607-735-9789
Weight classes: Men 56, 62, 69, 77, 85, 94, 105, 105+ Woman: 48, 53, 58, 63, 69, 75, 75+
Weigh ins for women 8-9am lift at 10am
Weigh ins for men 10:30-11:30am lift at 12:30
**** Sessions subject to change
**** BRING YOUR USAW CARD WITH YOU TO THE MEET ****
Please enter me in the _________ kg category for this meet. In consideration of my entry in the Jim’s Gym Last Chance Qualifier (individually and collectively, the “competition”). I certify that I am sufficiently physically fit to participate in the competition and I (and my parent or guardian, if I am a minor) hereby waive and release USA Weightlifting (the USAW), its directors, officers, officials and agents, the Niagara LWC, Jim’s Gym, CrossFit 607, and the competition’s sponsors and organizers of and from any cause of action, loss, liability, claim demand or expense of any kind whatsoever which I or my heirs or personal representatives may have bodily injury or illness and for any other cost, damage or loss suffered or incurred by me or on my behalf in connection with my travel to and from, and my participation in, the Competition and all related activities. The foregoing waiver and release shall not apply to injuries, damages and losses resulting from injuries or medical expenses covered by accidental death, dismemberment and/or loss of sight and medical insurance policies maintained by the USAW.
I (and my parents or guardian, if I am a minor) agree that the USAW and its agents, including the Competition’s sponsors and organizers, may make judgments (with
appropriate advice from available medical personnel) with respect to my treatment, hospitalization or other medical care in the event of my illness or accidental injury in connection with my participation in the Competition, if I become disabled or incompetent to make necessary and appropriate decisions for me as though they stood in a relationship to me of parent, guardian or next of kin if circumstances require the USAW, its agents or the Competition’s sponsors or organizers to make such judgments, and my next of kin (or my parent or guardian, if I am a minor) hereby release and agree to hold the USAW and its agents, Jim’s Gym/CrossFit607, and the Competition’s sponsors and organizers harmless from and against any expense, cause of action, liability, claim, demand or expense arising from good faith judgments made by the USAW, its agents and/or the Competition’s sponsors and organizers concerning the treatment, hospitalization and/or medical care in the event of any illness, injury or other emergency circumstance in connection with the Competition.
I (and my parent or guardian, if I am a minor) agree that I (and my parent or guardian, if I am a minor) will be financially responsible for treatment, hospitalization and other medical care rendered to me in the event of my illness, injury or other medical emergency circumstances in connection with the Competition, except to the extent my injuries and medical expenses, if any, are covered by accidental death, dismemberment and/or loss of sight and medical reimbursement insurance policies maintained by the USAW for my benefit, in which event I (and my parent or guardian, if I am a minor) nevertheless will continue to be financially responsible for expenses of treatment, hospitalization and other medical care in excess of such policies’ limits.
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY
DATE OF BIRTH________________AGE______
USAW NUMBER___________USAW MEMBER EXPIRATION DATE_______________
USAW CLUB AFFILIATION________________________________________None___________
ATHLETES UNDER AGE 18 MUST HAVE THE FOLLOWING SECTION COMPLETED BY THEIR PARENT OR LEGAL GUARDIAN.
(For athletes of minority age) I have explained to my son/daughter the aforementioned release and activity and their ramifications, and I further consent to his or her registration for this USAW activity under the conditions and their ramifications, and I further consent to his or her registration for this USAW activity under the conditions stipulated above.
PRINTED NAME_______________________________________ PARENT_____GUARDIAN_____