2001
Virginia Regional Tetrathlon
May 19 and 20,
2001
Entry Form
Organizer: Keith Hutcheson 540-364-4141
[email protected]
Closing Date: April 21, 2001
Secretary: Alice Laimbeer 540-937-3057
Entry Fee: $55
Entries must be
received by the closing date and must be complete. $35 of the entry fee is refundable
if the organizer or secretary is notified on or before the closing date. There will be no refunds after the
closing date.
Competitor:
___________________________________________
Date of Birth: _________
Address:
___________________________________________ Rating (as of 5/19/01): _____
___________________________________________
Phone: ( )
_______________
Pony Club:
___________________________________________
Division (i.e.
Pre-Novice Girl):
_________________________________________________
Jumping:
q
with
your division
q taking 200 point penalty and jumping one
division lower
q taking 400 point penalty and jumping two
divisions lower
Name of Horse or
Pony:
_______________________________________
q
I will be sharing a
horse with ____________________________________
Please check the
appropriate boxes,
Stabling:
q
Friday night
q
Saturday night
Ice Cream Social:
q
Competitors ____ # of Non-competitors @ $3
each
q
I will
be sharing a gun with ___________________________________________
I agree to hold
harmless Glenwood Park and its trustees, Casanova-Warrenton Pony Club, USPC and
the organizers from all liability for accidents, injury, illness or death
suffered during or in connection with this competition.
Signature of
Competitor:
_____________________________________________ Date: ____________
Signature of Parent
or Guardian:
_____________________________________ Date: ____________
Please Return: q
Signed
Entry and Rally Release Forms
Mail Entries
to:
q check made payable to
CWPC including:
CWPC
$55 entry fee
c/o Alice Laimbeer
$15 per night for stabling
P.O. Box 239
$3
for each non-competitor attending ice cream social
Amissville, VA
20106
q
12 month negative
Coggins test
q
Emergency Medical
Release form