Entry Form Home UPA Powerlifting & Bench Press National Championship Entry Form UPA POWerlifting & Bench Press National championship March 18 & 19, 2023 Grand River Center -Exhibit Hall BDubuque, IA 2024 XPC ARNOLD CLASSIC QUALIFIERUpon payment, no refund requests will be accepted. Thank you Please make sure you reveiw the weigh in times before you enter the meet. There is absolutely no special weigh in times. No same day weigh ins. If you can’t make the weign in times. Don’t enter the meet. Thank you. Please print the hard copy entry form at www.UPAPower.com under Powerlifting. All information about the UPA Power Weekend meet is on the hard copy entry form. UPA Powerlifting & Bench Press National Championship Name(Required) First Last Street Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Age (Your age on meet day)(Required) Date of Birth(Required) MM slash DD slash YYYY UPA Card # (If Applicable) UPA Card Expiration Date MM slash DD slash YYYY 1st Division ($100) *Men's Open full power is on Sat. and Age Divisions are on Sun. So you can't enter both.(Required)Mens Open Full-PowerMens Teen Full-PowerMens Junior Full-PowerMens Submasters Full-PowerMens Masters Full-PowerWomens Open Full-PowerWomens Teen Full-PowerWomens Junior Full-PowerWomens Submasters Full-PowerWomens Masters Full-PowerMens Open Bench-OnlyMens Teen Bench-OnlyMens Junior Bench-OnlyMens Submasters Bench-OnlyMens Masters Bench-OnlyWomens Open Bench-OnlyWomens Teen Bench-OnlyWomens Junior Bench-OnlyWomens Submasters Bench-OnlyWomens Masters Bench-Only2nd Division (Add $40)No Additional DivisionMens Open Full-PowerMens Teen Full-PowerMens Junior Full-PowerMens Submasters Full-PowerMens Masters Full-PowerWomens Open Full-PowerWomens Teen Full-PowerWomens Junior Full-PowerWomens Submasters Full-PowerWomens Masters Full-PowerMens Open Bench-OnlyMens Teen Bench-OnlyMens Junior Bench-OnlyMens Submasters Bench-OnlyMens Masters Bench-OnlyWomens Open Bench-OnlyWomens Teen Bench-OnlyWomens Junior Bench-OnlyWomens Submasters Bench-OnlyWomens Masters Bench-Only3rd Division (Add $40)No Additional DivisionsMens Open Full-PowerMens Teen Full-PowerMens Junior Full-PowerMens Submasters Full-PowerMens Masters Full-PowerWomens Open Full-PowerWomens Teen Full-PowerWomens Junior Full-PowerWomens Submasters Full-PowerWomens Masters Full-PowerMens Open Bench-OnlyMens Teen Bench-OnlyMens Junior Bench-OnlyMens Submasters Bench-OnlyMens Masters Bench-OnlyWomens Open Bench-OnlyWomens Teen Bench-OnlyWomens Junior Bench-OnlyWomens Submasters Bench-OnlyWomens Masters Bench-Only4th Division (Add $40)No Additional DivisionsMens Open Full-PowerMens Teen Full-PowerMens Junior Full-PowerMens Submasters Full-PowerMens Masters Full-PowerWomens Open Full-PowerWomens Teen Full-PowerWomens Junior Full-PowerWomens Submasters Full-PowerWomens Masters Full-PowerMens Open Bench-OnlyMens Teen Bench-OnlyMens Junior Bench-OnlyMens Submasters Bench-OnlyMens Masters Bench-OnlyWomens Open Bench-OnlyWomens Teen Bench-OnlyWomens Junior Bench-OnlyWomens Submasters Bench-OnlyWomens Masters Bench-OnlyWeight Class(Required)97 - Women's weight classes start here.105114 - Men's weight classes start here.123132148165181198220242275308308+ (Women's)SHWTeam Name (If Applicable) Competing Raw, Raw Elite (Full Power Only) or Equipped?(Required)RawRaw Elite (Full Power Only)EquippedSingle Division Entrance Fee(Required)$100 Full Power$100 Bench OnlyAdditional Divisions Add $10.00 for UPA-AD (Drug-Tested) Add $40.00 (2nd Division) Add $40.00 (3rd Division) Add $40.00 (4th Division) Add $50.00 for Team entry (Coaches fee) Need a Membership Card?Current UPA MemberAdd $40.00 for UPA Adult MembershipAdd $25.00 for UPA Teen MembershipMeet T-shirt (Optional)No ThanksS ($20.00)M ($20.00)L ($20.00)XL ($20.00)2-XL ($20.00)3-XL ($20.00)Add $30.00 for entry after 3/3/23 Price: Please Check to Accept Payment Transaction Fees(Required) Yes, I will accept payment transaction fees 5% Paypal Fees Price: $0.00 Total Release and Waiver(Required) I Have Read and Agree to WaiverIn consideration of being allowed to participate in any way in the UPA Powerlifting & Bench Press National Championship promoted by Bill Carpenter. and sanctioned by the United Powerlifting Association, LLC, its related events and activities, I, the undersigned, acknowledge, appreciate and agree that: 1. The risk of injury from the activities involved in this Event is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE PROMOTER AND/OR THE UPA, LLC or others, and assume full responsibility for my participation; and 2. I willingly agree to comply with the stated and customary terms and conditions for participation, if, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Promoter immediately; and 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE PROMOTER AND THE UPA, LLC and each of their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY DISABILITY, DEATH, or loss or damage to person or property associated with my presence at or participation in or in traveling to and from the Event, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I understand there is a random drug testing by urinalysis on a minimum of 10 % of all UPA-AD division lifters. The UPA will permanently ban any lifter testing positive for a banned substance from the UPA-AD division. I hereby grant the UPA, LLC Promoter and/or any other UPA, LLC -approved video or entertainment organization and all of their agents, successors, licensees and assigns, the right to photograph or otherwise reproduce (whether by film, tape, still photography or otherwise) my voice, appearance and name, and to exhibit, distribute, transmit, and/or otherwise exploit and all media, including without limitation, by means of still photography, motion pictures, radio, television, television motion pictures, video, printing on digital or any other medium now known or hereafter devised, including with respect also to any merchandising, advertising and/or publicity, and the right to use my name and information about me in any connection with any of the foregoing. The rights granted by me hereunder are granted for the entire universe and shall endure in perpetuity and no further compensation shall be payable to me at any time in connection therewith. Nothing contained herein shall be deemed to obligate the UPA, LLC Promoter, and/or any other UPA, LLC -approved video or entertainment organization, to photograph or otherwise reproduce my voice, appearance or name, or to make use of any rights granted herein. I also understand that the aforementioned rights may be reassigned at any time without further consent. I understand that the UPA, LLC, the Promoter and/or any UPA, LLC-approved video or entertainment organization, are videotaping and photographing the Event in express reliance upon the foregoing, and I represent and agree that I am free to grant the rights granted to the UPA, LLC Promoter and/or any other UPA, LLC -approved video or entertainment organization hereunder. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVE UP SUBSTAINTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.Signature (Use Mouse to Sign)(Required)Print Name(Required) Date of Signature(Required) MM slash DD slash YYYY Parent Must Sign If You Are Under 18 (Use Mouse to Sign)(Required)Print Name (Parent)(Required) Comments or QuestionsPayment Method*PayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Δ Upcoming UPA Events November 11 & 12, 2023 UPA Power Weekend – Dubuque, IA Click on the picture below. Nov. 18 & 19, 2023 UPA Big Iron Gym Hussey Classic – Omaha, NE