Office Use Only
Only ONE HORSE per entry form. PLEASE type or print clearly. Please indicate which week! Name of Horse or Pony
Gr Year
HUNTER DIVISIONS - please indicate Rider 1 or Rider 2 High Performance
Low Pre Green
1st Year Green
High Pre Green
2nd Year Green
Baby Green
Reg. Conformation
AO 3'3" - 18-35
Green Conf.
AO 3'3" - 36+
Performance 3'3" Performance 3'6"
AO 18-35 AO 36 +
Sm Junior 15&U
Sm Pony
Sm Junior 16-17
Med Pony
AA 18-35
Lg Junior 15&U
Large Pony
AA 36-49
Lg Junior 16-17
S/M Green Pony
AA 50 & O
Large Green Pony
Mod. Child
Children's Htr. Pony
Mod. Adult
Hopeful Limit
Children's 14 & U Children's 15-17 Jr/Am Modified
Entries Close: March 23, 2012
Spring Gathering Katy, TX April 3 - 7, 2012
Make checks payable (in US Funds) and mail to: P.J.C.P 26901 West Brooks Road Waller, Texas 77484 281-924-6579 phone
USHJA Horse Reg #
THJA #
Equitation, Individual Hunter & Opportunity Classes by Rider Rider 1
Rider 2
High Children Low Junior
TJ 1.05
Low AO
Short Stirrup
TJ 1.15
High Jr/AO
Long Stirrup
Pony
Open1.25
TJ 0.80
Low Adult
Open1.35
TJ 1.20
High Adult
Open1.40
Name
Name USEF #
THJA # Birthdate
ASPCA #
City, State, Zip
City, State, Zip
Address
Phone
Phone
City, State, Zip
Fax
Fax
Rider #2 Signature:
Cell
Cell
Name
USEF #
THJA #
SS #
SS #
ASPCA #
Birthdate
SS #
City, State, Zip Is Rider / Driver / Vaulter a US Citizen? Write Yes or No
Non Showing Horse $100.00 = USEF Drug Fee @$16 (USEF $8; D/M $8) = USHJA Zone Support Fee = THJA Non-Member Fee @$10.00 =
Rider
USHJA NM Fee: $30
Owner
Rider
Trainer Trainer
Total Due =
Amount Enclosed: Stable With
Parent/Guardian Emergency Contact
Phone
Jumper Nomination @$175.00 =
Stalls will not be reserved without payment!
City, State, Zip
Name
Address
30 amp RV @ $275.00 = 50 amp RV @ $275.00 =
Late Fee (postmarked after March 23) $50.00=
Address
Sig.
Office Fee = Stall Fee - Permanent stalls @ $200.00 =
USEF NM Fee: ($30)
Address
Name
Ground Fee $50.00 per horse per day =
Owner
Address
Coach
Rider 2
TJ 1.00
Name
Alternate Payee
JUMPER DIVISIONS Indicate Rider 1 or Rider 2 Low Children
Rider/Handler #1 Signature:
THJA #
Foaled
TJ 0.90
Trainer Signature:
USEF #
Height
TJ 0.85
Owner / Agent Signature:
THJA #
Sex
Individual Jumper Classes by Rider Rider 1
Federation Entry Agreement I have read the United States Equestrian Federation, Inc. (the “Federation”) Entry Agreement (GR908.6) as printed in the Prize List for this 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 at 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 of the show must accompany this entry. This document waives important legal rights. Read it carefully before signing. 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. 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 #
Color
Sig. Name
Failure to present proper USEF/USHJA membership cards will result in non-member fees being charged.
Name I agree neither PJCP, 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.