Club representing: __________________________________
Date of birth: MONTH: _______/ DAY: _______/ YEAR: _______________
Gender: MALE / FEMALE: _________________________________
Weight class entering: _______________ KG
Membership card number: ______________________________________
Cheque payable to Daniel Paré, 203 Highview Drive, St. Thomas Ontario, Canada, N5R 5H6.
I understand that my participation to the 2015 Ontario Masters Open Weightlifting Championships is undertaken by me and is at my own risk and that St. Thomas Strength Athletics shall not be liable to me for any claims, injuries, actions, loss, loss of action, whatsoever, to my person or property and also release this facility from any discharge from all claims, injuries, damages, actions, or causes of action, and from all act of negligence, passive or active, on the part of St. Thomas Strength Athletics, its servants, agents or employees.
Signature: _________________________Date: ______________________
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