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Please enter me in the 2011 October Fest to be held on October 22, 2011 at Performance Initiatives, Inc. Facility at 2021 Tennessee Ave Savannah, GA 31404. I certify that I am a member in good standing with the USAW. In consideration of my entry in the competition, I do hereby waive, and release USA Weightlifting, GA/Alabama Local Weightlifting Committee, Performance Initiatives, Inc., Coastal Empire Weightlifting, Aldersgate United Methodist Church, Cross Fit of Savannah and their respective directors, officers, officials, agents and competition personnel, hereinafter known as the "Organizers," from any and all causes of action, loss, liability, claims and demands of every kind and nature, which I or my heirs or personal representatives may have for bodily injury, for expenses of medical treatment, hospitalization, and other care rendered to me in the event of my injury or illness, or for any and all other costs, damages or loses suffered or incurred by me or occasioned to me in connection with my travel to and from, and my participation in, the competition and related activities, except that the forgoing waiver and release shall not apply to injuries, damages, and losses resulting from the gross negligence and/or want of misconduct of the Organizers or to bodily injuries and medical expenses covered by accidental death, dismemberment and/or loss of sight and medical reimbursement insurance policies maintained by the Organizers.

I agree to be filmed and photographed under conditions approved and authorized by the USA Weightlifting, to include the use of my name, biographical information, public appearances, interviews, photographs, portrait and motion pictures and television recordings of my weightlifting performance and grant to Performance Initiatives, Inc., USA Weightlifting and Organizers the right to record and make use of the same, and to authorize others to do so in promoting the competition and the success of the weightlifting team on which I compete, to promote the image of Performance Initiatives, Inc. and USA Weightlifting, its sponsors and advertisers, and the sport of weightlifting, and to fund the activities of the Performance Initiatives, Inc. and USA Weightlifting.

I (and my parent or guardian, if I am a minor), agree that the Organizers and its agents, including competition personnel, may make judgments (with appropriate input from available medical personnel), as 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, should I be disabled or incompetent to make necessary and appropriate decisions concerning such treatment, hospitalization or other care. I authorize the Organizers, its agents and competition personnel to make such decisions for me as though they stood in a relationship to me of parent, guardian or next of kin should circumstances require the Organizers, its agents and competition personnel to make such judgments, and my next of kin cannot be timely and conveniently contacted to participate in the making of such judgments.

I hereby release and agree to hold the Organizers, its agents and competition personnel harmless from all expenses, causes of action, liability, claims and demands arising from good faith judgments made by the Organizers, its agents and competition personnel concerning my treatment, hospitalization and medical care in the event of my illness, injury or other emergent circumstances in connection with the competition.

I (and my parent or guardian, if I am a minor), agree that I will be financially responsible for treatment, hospitalization and other medical care rendered to me in the event of my illness, injury or other 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 Organizers for my benefit, in which event I will nevertheless continue to be financially responsible for expenses of treatment, hospitalization and other medical care in excess of such policies' limits.

PAGES 3 and 4 MUST BE COMPLETED AND SUBMITTED TOGETHER

NAME__________________________________________________ USAW #_______________

(Last) (First) (Middle)

Athlete’s Signature:_______________________________________________ Date:______________

e-mail:____________________________________________________________________________

ADDRESS__________________________________________________________________________

CITY_____________________________________ STATE_________ ZIP________________

PHONE (_______)__________ E-MAIL __________________________ AGE_______ DOB_________

COACH: __________________________________________________________________________

WILL THIS BE YOUR COACH AT THIS MEET? __YES __ NO (If no, then whom?)____________

Coach’s USAW #___________

(COACH MUST BE A CURRENT USA WEIGHTLIFTING MEMBER TO ACCESS THE WARM-UP ROOM)

USA WEIGHTLIFTING CLUB AFFILIATION__________________________________ CLUB #:____________

__ MALE __ FEMALE *U S. CITIZEN: __ YES __ NO

______School-age _______Junior ______Senior _______Master (age division_______)

*Athletes must be U.S. Citizens to compete*

UNDER AGE ATHLETES

ATHLETES UNDER 18 YEARS OF AGE MUST HAVE THE FOLLOWING SECTION COMPLETED BY A PARENT OR GUARDIAN

I have explained to my son/daughter the aforementioned releases and conditions and their ramifications and I further consent to his/her registration for this USA Weightlifting activity under the above stipulated conditions.

SIGNATURE_____________________________________________________________ DATE__________________

PRINTED NAME: _______________________________________________________________ (Parent or Guardian)

IF YOU ARE UNDER 18 YEARS AND YOU HAVE FAILED TO HAVE YOUR PARENT OR GUARDIAN SIGN THIS RELEASE, YOU WILL NOT BE PERMITTED TO LIFT or COMPETE.