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Office Use Only

Name of Horse or Pony

Gr Year

Sm Junior

Sm Pony

AA 18-35

High Pre Green

Lg Junior

Med Pony

AA 36-49

2nd Year Green

Baby Green

Children's 14 & U

Large Pony

AA 50 & O

Performance 3'6"

AO 36 +

Children's 15-17

S/M Green Pony

Mod. Child

Performance 3'3"

AO 18-35

Children's Htr. Pony

Large Green Pony

AO 3'3" - 18-35

Jr/Am Modified

Hopeful

Limit

1st Year Green

Low Pre Green

USHJA Horse Reg #

Rider 1

Make checks payable (in US Funds) and mail to: Great Southwest Equestrian Center 2501 South Mason Rd.; Suite 100 Katy, TX 77450 281-578-7669 phone

THJA #

Equitation, Individual Hunter & Opportunity Classes by Rider

HUNTER DIVISIONS - please indicate Rider 1 or Rider 2 High Performance

Entries Close: September 17, 2012

Great Southwest Fall Classic Horse Show Katy, TX September 27-30, 2012

Only ONE HORSE per entry form. PLEASE type or print clearly. Please indicate which week!

Rider 2

Color

Sex

Individual Jumper Classes by Rider Rider 1

Height

JUMPER DIVISIONS Indicate Rider 1 or Rider 2

Rider 2

TJ 0.85

Low Child/Ad

TJ 0.95

High Children

TJ 1.00

High Adult

TJ 1.15

Low Jr/AO

TJ 1.20

High Jr/AO

Open1.30

Open1.40

Mod. Adult Short or Long Stirrup

Low Hunter

AO 3'3" - 36 +

Foaled

Federation Entry Agreement I have read the United States Equestrian Federation, Inc. (the "Federation") Entry Agreement (GR906.4) as printed in the Prize List for Britannia Farm Winter Horse Show Ground Fee $50.00 per horse = ("Competition") and agree to all of its provisions. I understand and agree that by entering this Competition, I am subject to Federation Rules, the Prize List, and local rules of Office Fee = the competition. I agree to waive the right to the use of my photos from the competition, and agree that any actions against the Federation must be brought in New York State. A Negative Coggins Test dated within one year Release, Assumption of Risk, Waiver and Indemnification 30 amp & 50 amp RV @ $225.00 = of the show must accompany this entry. This document waives important legal rights. Read it carefully before signing. Stall Fee Permanent stalls @ $180.00 = I AGREE in consideration for my participation in this Competition to the following: I AGREE that the "Federation" and "Competition" as used above includes all of their officials, officers, directors, employees, agents, personnel, volunteers and affiliated organizations. Jumper Nomination @$150.00 = I AGREE that I choose to participate voluntarily in the Competition with my horse, as a rider, driver, handler, vaulter, longeur, lessee, owner, agent, coach, trainer, or as parent or guardian of a junior exhibitor. I am fully aware and acknowledge that horse sports and the Competition involve inherent dangerous risks of accident, loss, and serious bodily injury including broken bones, head injuries, trauma, pain, suffering, or death ("Harm"). Non Showing Horse $100.00 = I AGREE to hold harmless and release the Federation and the Competition from all claims for money damages or otherwise for any Harm to me or my horse and for any Harm of any nature caused by me or my horse to others, even if the Harm arises or results, directly or indirectly, from the negligence of the Federation or the Competition. USEF Drug Fee @$16 (USEF $8; D/M $8) = I AGREE to expressly assume all risks of Harm to me or my horse, including Harm resulting from the negligence of the Federation or the Competition. I AGREE to indemnify (that is, to pay any losses, damages, or costs incurred by) the Federation and the Competition and to hold them harmless with respect to claims for Harm to me or my horse, and for claims made by others for any Harm USHJA Zone Support Fee = caused by me or my horse while at the Competition. I have read the Federation Rules about protective equipment, including GR801 and, if applicable, EV114 and I understand that I am entitled to wear protective equipment without penalty, and I acknowledge that the Federation strongly encourages me to do so while WARNING that no protective equipment can guard against all injuries. If I am a parent or guardian of a junior exhibitor, I consent to the child's participation and AGREE THJA Non-Member Fee @$10.00 = to all of the above provisions and AGREE to assume all of the obligations of this Release on the child's behalf. I represent that I have the requisite training, coaching and abilities to safely compete in this competition. I AGREE that if I am injured at this competition, the medical personnel treating my injuries may provide information on my injury and treatment to the Federation on the official USEF accident/injury report form. BY SIGNING BELOW, I AGREE to be bound by all applicable USEF NM Fee: ($30) Federation Rules and all terms and provisions of this entry blank and all terms and provisions of this Prize List. If I am signing and submitting this Agreement electronically, I acknowledge that my electronic signature shall have the same validity, Owner Rider Trainer force and effect as if I affixed my signature by my own hand. BOD 1/23/11 Effective 12/1/11

Owner / Agent Signature:

Trainer Signature:

Name USEF #

USEF #

Owner

Name

Name THJA #

USHJA NM Fee: $30

Rider #1 Signature:

THJA #

THJA # Birthdate

Address

ASPCA #

City, State, Zip

City, State, Zip

Address

Phone

Phone

City, State, Zip

Fax

Fax

Rider #2 Signature:

Cell

Cell

Name

Email

Email

USEF #

THJA #

SS #

SS #

ASPCA #

Birthdate

Name SS #

Coach Sig.

City, State, Zip Is Rider / Driver / Vaulter a US Citizen? Write Yes or No

Name

Parent/Guardian Emergency Contact

Phone

Name

Email Address: (required)

Amount Enclosed: Stable With

Address

Sig.

Late Fee (postmarked after Sept 17) $50.00=

Stalls will not be reserved without payment!

City, State, Zip

Name

Address

Trainer

Total Due =

USEF #

Address

Alternate Payee

Rider

I agree neither GSEC, nor the Show Committee, nor Pauline Cook dba Britannia Farm, nor the officials and/or staff of the show will be responsible for any accident, damage, loss or injury to count, owner, rider or other persons or property. It will be the condition of entry that each exhibitor shall hold the horse show and its management blameless for any loss or accident to any animal, person or property that may occur from sickness, fire and otherwise at this show. Under Texas law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in equine activities resulting exclusively from the inherent risks of equine activities.

Failure to present proper USEF/USHJA membership cards will result in non-member fees being charged.


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