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