USA WEIGHTLIFTING

CLUB COACHING APPLICATION FORM

DATE OF COURSE: _________May 10, 11, 12, 2002_____________________ RETURN By: May 7^th, 2002

CLINIC COORDINATIOR: MIKE BURGENER

ADDRESS: 32067 VIA VERA, BONSALL, Calif. 92003

SCHOOL ADDRESSS:  Course will be held at Fresno State University or Mc Clane H.S. in Fresno.

TELEPHONE: 760-941-5852 (H)760-727-7284, EXT 3330 (W), 760-8095157 (cell)

E-Mail: olylfts1@aol.comor mburgene@vusd.k12.ca.us or rtucker@csufresno.edu rich tucker at Fresno state university.

PARTICIPANT INFORMATION:

NAME: __________________________________________ DATE OF BIRTH: __________________

ADDRESSS: ______________________________ CITY________________ 

STATE_____________ZIP____________

HOME PHONE: ___________________ BUSINESS PHONE: __________________________

AMOUNT OF CHECK ENCLOSED: _______________ CHECK NO. ___________________

(CHECKS SHOULD BE MADE PAYABLE TO USAW.CREDIT CARDS ARE NOT ACCEPTED)

T-SHIRT SIZE:______________________

FEES:

$250 USAW MEMBER (YOU MUST ENCLOSE A COPY OF YOUR USAW CARD)

$285 NON MEMBER($25 goes to membership.)

NOTE: NO DISCOUNT WILL BE GIVEN ON THE COST OF THE COURSE TO PARTICIPANTS WHO ALREADY HAVE COURSE MATERIALS.

WAIVER OF LIABILITY:

In consideration of my participation in any USA Weightlifting program, I acknowledge that I understand the nature of the activity and that I, and or my minor child, am qualified, in good health, and in proper physical condition to participate in such activity.I fully understand that weightlifting involves a risk of serious bodily injury, including permanent disability, paralysis, and death, and that these and other risks may be caused by my own actions or inaction, those of others participating in the event, the conditions in which the event takes place or the negligence of the releasers named below, and that there may be other risks either not known to me or not foreseen at this time and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my participation in the activity.

I hereby release, discharge and covenant not to sue USA Weightlifting, their respective administrators, directors, agents, officers, volunteers and employees and any sponsors and advertisers of any USAW sanctioned event in which I participate (each considered one of the releasers herein) from all liability, claims, demands, loses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the releasers.This release, waiver of liability and express assumption of risk agreement does not apply to any liability, claims, demands, losses or damages arising out of the gross negligence of or intentional, willful or wanton misconduct of releasers.If I or anyone on my and/or my minor child’s behalf makes a claim against any of the releasers, I will indemnify, defend, save and hold harmless each of the releasers from any loss, liability, damage or cost which may incur as a result of such claim.

I acknowledge that I have read this release, waiver of liability and express assumption of risk agreement and fully understand it.

X _______________________________________  DATE SIGNED: __________________________