USPANEWYORKSTATE

POWERLIFTINGCHAMPIONSHIP

Dateand
Time

Saturday,November10,2012at10:00AM

Location

QualityHotel&SuitesattheFalls,240FirstSt,NiagaraFallsNY14303,Phone(716)2821212,

Sanctioned
Eligibility

Divisions
Weight
Classes
Rules

Schedule

Awards
Entryfee

Deadline

Payment

Questions

Website

Reservations:18772821212orvisithttp://www.qualityniagarafalls.com/

UnitedStatesPowerliftingAssociation(USPA)

Anymaleorfemaleage13yearsorolder.LiftersmustbecurrentUSPAmembers.Membershipswillbeavailable
attheweighinfor$30(HighSchool$15)Membershipgoodforoneyearfromdateofpurchase.

Open,Junior1315,1617,1819,2023,Submaster3539,Master40+RawandAssisted

Men:114,123,132,148,165,181,198,220,242,275,308,308+
Women:97,105,114,123,132,148,165,181,198,198+

Onepiecesingletmustbeworn,asaminimumforalllifters.Rawdivision:liftersarerequiredtowearasinglet
andatshirtinthesquat,andbenchpress.Atshirtisoptionalinthedeadlift.Longsocksarerequiredinthe
deadliftforalllifters.Longsocksmeansthesockisoverthecalf.Rawrulesalsoallowa4inchwidebeltwith
buckleorlever.NoVelcrobeltsandnopaddingontheinsideofthebelt.Wristwrapsandkneesleevesarealso
allowedintherawdivision.ClassicDivision:allowskneewrapswitheverythingelsebeingraw.
SinglePlyrules:SinglePlysquat,benchanddeadliftsuitsonly!NoVelcrostrapsonsquat/deadliftsuit.Velcrois
allowedonbenchshirt,butmustclosethebackcompletelynoopenbackshirts.Briefswithnolegsareallowed
(Briefunderwear,noboxers).Topofbriefcannotgoabovethenavel.SeeUSPArulebookatwww.uspla.org.

EarlyWeighinandEquipmentCheck:QualityInn&Suites,Friday,November9,2012from10:00AM2:00PM
and5:00PM7:00PM
RegularWeighinandEquipmentCheck:Saturday,November10,2012from7:30AM9:00AM
RulesBriefing:Saturdayat9:15AM,WarmUp:Saturdayat9:30AM,LiftingBegins:Saturdayat10:00AM

DivisionbyWeightClassandBestLifters

$75.00forFullPowerlifting,$65.00perlifterforBenchOnly,DeadliftOnlyorPush/Pull,add$20foranadditional
contestordivision.Teamentryfeeis$50.00forentireteam.Teamrosterformavailablehere:
http://www.uspla.org/resources.htm.

EntriesmustbepostmarkedbyWednesday,October31,2012.Entriespostmarkedafterdeadlinemustpaylate
feeof$10.Noentriesacceptedondayofcontest.Pleasemailyourentryontime.

Makecheckormoneyorderpayableto:DennisBrochey
Sendentryformandpaymentto:DennisBrochey,205NFifthSt,LewistonNY14092

CallDennisBrochey,USPANYSChairpersonandMeetDirectorat7167544009(day),7162003533(evening),or
email:dennis.brochey@gmail.com.

http://uspla.org/home/nationwidemeetlisttoprintadditionalcopiesoftheposterandentryform.
ForcurrentUSPARulesBookvisittheUSPAWebsiteathttp://www.uspla.org

USPANewYorkState PowerliftingChampionship
at

QualityHotel&SuitesattheFalls
240FirstSt,NiagaraFallsNY14303

SATURDAY,NOVEMBER10,2012
ApplicationDeadline:Wednesday,October31,2012
NOENTRIESACCEPTEDONDAYOFCONTEST

____________________________________________

____________________

(______)_______________

PLEASEPRINTNAME(FIRST,MIANDLAST)

DATEOFBIRTH(MM/DD/YYYY)

PHONENUMBER

____________________________________________

__________________________________________________

HOMEADDRESS

EMAILADDRESS

__________________________ ________________

CITY

________________________

____________________

STATE

ZIPCODE

USPACARDNUMBER

USPACARDEXPIRATIONDATE

Contest(CircleAllthatApply):

BENCH

DEADLIFT

Gender(CircleOne):

MALE

FEMALE

Equipment(CircleOne):

RAW

CLASSIC

PUSH/PULL

POWERLIFTING

SINGLEPLY

MULTIPLY

WomensWeight(CircleOne):

97105114123132148165181198198+

MensWeight(CircleOne):

114123132148165181198220242275308308+

Division(CircleDivisions):

JUNIOR1315JUNIOR1617JUNIOR1819JUNIOR2023OPEN13+
SUBMASTER3539MASTERS4044MASTERS45495054555960646569
7074757980+

Cost(CircleAllthatApply): FULLPLMEET:$75.00BENCHONLY:$65.00DEADLIFTONLY:$65.00PUSH/PULL:$65.00

ADDITIONALDIVISIONORCONTEST:$20.00 TEAMENTRY:$50.00

USPACARD$30.00USPAHIGHSCHOOLCARD:$15.00

LATEFEE$10.00

AmountEnclosed

$______________

SignandDate

_______________________________________________

____________________

PLEASESIGN

DATE(MM/DD/YYYY)

Pleasefullycompleteapplication,READandSIGNwaiveronback,andmailwithcheckto:
DENNISBROCHEY,205NFIFTHST,LEWISTONNY14092.Makecheckspayableto:DENNISBROCHEY.Contactmeat
dennis.brochey@gmail.comorcall(716)2003533withquestions.

RELEASEOFLIABILITYREADBEFORESIGNING

InconsiderationofbeingallowedtoparticipateinanywayinapowerliftingmeetsanctionedbytheUSPA,itsrelatedeventsand
activities,

I,____________________________________________,theundersigned,acknowledge,appreciate,andagreethat:
ParticipantsNameHere

1.
The risk of injury from the activities involved in this program is significant, including the potential for permanent
paralysisanddeath,andwhileparticularskills,equipment,andpersonaldisciplinemayreducethisrisk,theriskofseriousinjury
doesexist;and,

2.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE
NEGLIGENCEOFTHERELEASEESorothers,andassumefullresponsibilityformyparticipation;and,

3.
Iwillinglyagreetocomplywiththestatedandcustomarytermsandconditionsforparticipation.If,however,Iobserve
anyunusualsignificanthazardduringmypresenceorparticipation,Iwillremovemyselffromparticipationandbringsuchtothe
attentionoftheUSPAofficialsimmediately;and,

4.
I,formyselfandonbehalfofmyheirs,assigns,personalrepresentativesandnextofkin,HEREBYRELEASE,INDEMNIFY,
AND HOLD HARMLESS THE Meet Director/promoter, USPA and, their officers, officials, agents and/or employees, other
participants,sponsoringagencies,sponsors,advertisers,and,ifapplicable,ownersandlessorsofpremisesusedfortheactivity
("Releasees"),WITHRESPECTTOANYANDALLINJURY,DISABILITY,DEATH,orlossordamagetopersonorproperty,WHETHER
ARISINGFROMTHENEGLIGENCEOFTHERELEASEESOROTHERWISE,tothefullestextentpermittedbylaw.

IHAVEREADTHISRELEASEOFLIABILITYANDASSUMPTIONOFRISKAGREEMENT,FULLYUNDERSTANDITSTERMS,UNDERSTAND
THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY
INDUCEMENT.

x________________________________
________

__________________
ParticipantsSignature

Age

DateSigned

FORPARENTS/GUARDIANSOFPARTICIPANTSOFMINORITYAGE
(UNDERAGE18ATTIMEOFREGISTRATION)

ThisistocertifythatI,asparent/guardianwithlegalresponsibilityforthisparticipant,doconsentandagreetohis/herreleaseas
providedaboveofalltheReleases,and,formyself,myheirs,assigns,andnextofkin,Ireleaseandagreetoindemnifyandhold
harmlesstheReleasesfromanyandallliabilitiesincidenttomyminorchild'sinvolvementorparticipationintheseprogramsas
providedabove,EVENIFARISINGFROMTHENEGLIGENCEOFTHERELEASEES,tothefullestextentpermittedbylaw.

x________________________________
__________________________________
__________________
Parent/GuardiansSignature

EmergencyPhone#

DateSigned

Note:PleaseSignandMailthisReleaseofLiabilitywithyourentryformto:
DennisBrochey
USPANYStateChairman
205NFifthSt
LewistonNY14092