Page 1

Office Use Only

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

March 14 - 17, 2013 Gr Year

Low Pre Green

Sm Junior

High Pre Green

Lg Junior

2nd Year Green

AO 3'3" - 18-35

Jr/Am Modified

Performance 3'6"

AO 3'3" - 36+

Limit

Performance 3'3"

AO 3'6" - 18-35

Children's 14 & U

Baby Green

AO 3'6" - 36 +

Children's 15-17

USHJA Horse Reg #

THJA #

Equitation, Individual Hunter & Opportunity Classes by Rider

HUNTER DIVISIONS - please indicate Rider 1 or Rider 2 1st Year Green

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

Katy, TX

Name of Horse or Pony

High Performance

Entries Close: March 5, 2013

Great Southwest Spring Round-Up

Color

Individual Jumper Classes by Rider

AA 36-49

TJ 0.80

Low Child/Ad

Large Pony

AA 50 & O

TJ 1.00

High Children

S/M Green Pony

Mod. Child

TJ 1.05

High Adult

Large Green Pony

Mod. Adult

TJ 1.15

Low Jr/AO

Children's Htr. Pony

Short/Long Stirrup

TJ 1.20

High Jr/AO

Hopeful

Low Hunter

Open1.30

Open1.35

Trainer Signature:

Rider 1

Rider 2

Rider 1

A Negative Coggins Test dated within one year of the show must accompany this entry.

USEF #

THJA # Birthdate

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

SS #

Coach Sig.

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

50 amp RV New Section #1-30 @ $250.00 = 30 amp Old Section RV @ $200.00 = 50 amp Old Section RV @ $200.00 = Jumper Nomination @$150.00 = Non Showing Horse $100.00 = USEF Drug Fee @$16 (USEF $8; D/M $8) =$ 16.00

Emergency Contact

Name

Email Address:

USHJA NM Fee: $30

Owner

Rider

Trainer Trainer

Amount Enclosed:

Stalls will not be reserved without payment!

Stable With

Name

Parent/Guardian

Phone

Rider

Late Fee (postmarked after March 5) $50.00=

City, State, Zip Sig.

Owner

Total Due =

Address

Name

Address

30 amp RV New Section #1-30 @ $250.00 =

USEF NM Fee: ($30)

USEF #

Address

Name

Office Fee =$ 50.00 Stall Fee - Permanent stalls @ $200.00 =

USHJA Zone Support Fee =$ 2.00

Address

Alternate Payee

Ground Fee $50.00 per horse per day =

Name THJA #

Rider 2

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

Rider/Handler #1 Signature:

Name THJA #

JUMPER DIVISIONS Indicate Rider 1 or Rider 2

Med Pony

I AGREE in consideration for my participation in this Competition [Great Southwest Spring Round-Up Horse Show] 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. 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”). 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. 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 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 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 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, force and effect as if I affixed my signature by my own hand. BOD 1/23/11 Effective 12/1/11

USEF #

Foaled

AA 18-35

Release, Assumption of Risk, Waiver and Indemnification This document waives important legal rights. Read it carefully before signing.

Name

Height

Sm Pony

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 [GSEC Spring Round Up Horse Show] (“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 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.

Owner / Agent Signature:

Sex

I agree neither GSEC, nor the Show Committee, nor Pauline Cook 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.


GSEC%20Spring%20Round%20Up%202013%20Entry  

http://www.gswec.com/downloads/2013PrizeLists/springroundup/GSEC%20Spring%20Round%20Up%202013%20Entry.pdf

Advertisement
Read more
Read more
Similar to
Popular now
Just for you