Adaptive and Para Bench Application Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you currently a member of USA Powerlifting?
*
Please Select
Yes
No
Enter USA Powerlifting Member ID
Informational links for each division
Adaptive Division information
Para Bench Division information
Division you are applying for?
*
Please Select
Adaptive
Para Bench
Please describe your impairment in medical terms?
*
Please describe what rule or rules you cannot 100% adhere to?
*
Please describe what accommodations are required, if any?
*
Any comments, questions, or concerns?
By signing below, I agree to the following terms:
- I affirm that I have read the description of the division for which I am applying and that I meet the eligibility criteria for that division
- I affirm that all the information I provided in this form is accurate and truthful
- I understand that as a condition of approval for participation in USA Powerlifting, I must provide an official letter from a physician that
Documents the impairment/diagnosis
Supports participation in the sport of powerlifting
Signature
*
Submit
Should be Empty: