Kentucky Fall Classic Horse Show
October 3-5, 2013

25th UPHA CHAPTER 9 KENTUCKY FALL CLASSIC HORSE SHOW

October 3 - 6, 2012

Kentucky Horse Park, Lexington, Kentucky

Entries close September 21, 2012

One Horse per entry Blank                                                                  Mail To: Kentucky Fall Classic Horse Show

Make checks payable to:                                                                                                     65 Old Taylorsville Road

Kentucky Fall Classic Horse Show                                                                                           Shelbyville, KY 40065

Entries may be paid by credit card below                                    Phone (502) 647-0076 or Fax (502) 633-6207

PLEASE PRINT OR TYPE (Fill out completely)

Owner______________________________________ USEF #_________ ASHA#_____________________________________________ AHHS#_________ARHPA#________

Address_____________________________________________________ City/State/Zip_____________________

Phone #______________________________ Cell Phone #__________________________ email_____________

Trainer______________________________________ USEF #_________ ASHA#_____________________________________________ AHHS#_________ARHPA#________

Address_____________________________________________________ City/State/Zip__________________

Phone #______________________________ Cell Phone #__________________________ email_____________

Rider/Driver/Handler__________________________ USEF #_________ ASHA#_____________________________________________ AHHS#_________ARHPA#________

Address_____________________________________________________ City/State/Zip_____________________

Phone #______________________________ Cell Phone #__________________________ email_____________

Make Checks payable to:______________________________________ Social Security /Tax ID_____________

Address____________________________________________________ City/State/Zip_____________________

 

Office use

Horse Name

Registration #

USEF #

Color

Sex

Age

Height

Class #

 

 

 

 

 

 

Total Fees

Entry Fee

 

 

 

 

 

 

 

 

       

TOTAL ENTRY FEES

$

#

STALLS @ $125 EACH

$

#

STALLS $40 PER DAY (including EARLY SHIP IN)

$

#

GROUNDS FEE (Horses showing not using a stall) @ $15

$

#

USEF DRUG FEE @ $16 PER HORSE ($8 Drug & Med/$8 Horse)

$

#

USEF NON-MEMBER FEE @ $30

$

#

USEF AMATEUR MEMBER FEE (If no USEF Amateur Card) @ $30

$

#

OFFICE FEE PER HORSE

$                        20.00

#

DONATION CARDINAL HILL REHABILITATIONAL HOSPITAL

$

 

TOTAL REMITTANCE

$

        I would like to donate my winnings to support the UPHA Chapter 9 Kentucky Fall Classic Horse Show

Premium Checks not cashed within 90 days of issue will be voided and monies refunded to UPHA Chapter 9 Kentucky Fall Classic Horse Show.

USEF ENTRY AGREEMENT ON THE BACK MUST BE SIGNED.    Signed:    YES       NO

CHECK #____________ AMOUNT $_______ DATE RECEIVED______ WE ALSO ACCEPT: VISA________ MASTER CARD____________

CARD #_________________________________EXPIRATION DATE__________SECURITY CODE_________________________

CARD HOLDER NAME (please print)_______________________________CARD HOLDER SIGNATURE____________________

ALL HORSES MUST HAVE NEGATIVE COGGINS TEST PERFORMED WITHIN 12 MONTHS OF SHOW, AND HEALTH PAPERS FOR ALL HORSES CURRENT WITHIN 30 DAYS

CHECK #              AMOUNT $         DATE RECEIVED               


Federation Entry Agreement

By entering a Federation-licensed Competition and signing this entry blank as the Owner, Lessee, Trainer, Manager, Agent, Coach, Driver, Rider, Handler, Vaulter or Longeur and on behalf of myself and my principals, representatives, employees and agents, I agree that I am subject to the Bylaws and Rules of The United States Equestrian Federation, Inc. (the “Federation”) and the local rules of Kentucky Spring Premier. I agree to be bound by the Bylaws and Rules of the Federation and of the competition. I will accept as final the decision of the Hearing Committee on any question arising under the Rules, and agree to release and hold harmless the competition, the Federation, their officials, directors and employees for any action taken under the Rules. I represent that I am eligible to enter and/or participate under the Rules, and every horse I am entering is eligible as entered. I also agree that as a condition of and in consideration of acceptance of entry, the Federation and/or the Competition may use or assign photographs, videos, audios, cable - casts, broadcasts, internet, film, new media or other likenesses of me and my horse taken during the course of the competition for the promotion, coverage or benefit of the competition, sport, or the Federation. Those likenesses shall not be used to advertise a product and they may not be used in such a way as to jeopardize amateur status. I hereby expressly and irrevocably waive and release any rights in connection with such use, including any claim to compensation, invasion of privacy, right of publicity, or to misappropriation. The construction and application of Federation rules are governed by the laws of the State of New York, and any action instituted against the Federation must be filed in New York State. See GR908.4

Federation Release, Assumption of Risk, Waiver, and Indemnification

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 herein includes the Licensee and Competition Management, as well as all of their officials, officers, directors, employees, agents, personnel, volunteers and Federation affiliates.

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.

Circle all that apply                                      

Rider/Driver/Handler/Owner/Agent/Trainer/Coach

Print Name  ______________________________________________

Signature ________________________________________________

Circle all that apply

Rider/Driver/Handler/Owner/Agent/ Trainer/Coach

Print Name  ______________________________________________

Signature ________________________________________________

Circle all that apply

Rider/Driver/Handler/Owner/Agent/ Trainer/Coach

Print Name  ______________________________________________

Signature ________________________________________________

 

Required if Rider/Driver/Handler/Vaulter/Longeur is a minor

Print Name  ______________________________________________

Parent/Guardian Signature____________________________________

Emergency Contact Phone ____________________________        Is Rider/Driver/Vaulter a U.S. Citizen?: ___ Yes ___ No



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