Name

First Name

Last Name

Samson Challenge Completed

By checking I verify that I have completed the Samson Challenge of 1,000 pushups in 24 hours & agree to the terms & rules of the drawing.

Option 1

Option 2

Date Samson Challenge Completed

What day were the pushups done?

MM

DD

YYYY

Samson Challenge Start Time

Hour

Minute

Second

AM PM

Samson Challenge End Time

Hour

Minute

Second

AM PM