QSLB GOLD Entry Form 2014 Show Site Date Horse’s Name Passport Sex Breed Age Height Colour Achievements Rider’s Name Jr DOB Address City, Province Tel. # Home Tel. # Work P. C. Email EC # OEF # DC # City, Province Tel. # Home Tel. # Work P. C. Email EC # OEF # DC # Owners Name Address Please use a separate form for Silver and Gold shows NATIONAL SHOW FEES AA / OPEN /JUNIOR $35 Per Class / FEI $50 Per Class PLEASE INDICATE CLASS BY CIRCLING ONE OF THE FOLLOWING: AA / OPEN / JUNIOR LEVEL (ie First) TEST NUMBER (ie 2) Entry Fee Dressage Canada Levy fee (mandatory) $ 7.00 Drug testing fee (mandatory) $ 7.91 $ Administration Fee for National Shows – QSLB Member $ 10.00 $ Administration Fee for National Shows – Non-QSLB Member TOTAL AMOUNT DUE (payable to QSLB) $ 25.00 $ $ VOLUNTEERING AT SHOW BEFORE/AFTER RIDE? Please circle if you can-you will be contacted by the Volunteer Coordinator if required. Have you enclosed copies of all required 2014 Membership cards ? Are all the appropriate signatures on the liability waiver form (see below)? Have you enclosed payment in full? Coggins form copy for Winter's End show? LIABILITY FORM ON REVERSE MUST BE FILLED IN AND SIGNED BY THE RIDER/GUARDIAN,THE OWNER OF THE HORSE AND THE PERSON RESPONSIBLE FOR THE HORSE AT THIS SHOW QSLB LIABILILTY WAIVER Name of Competitor DOB if Junior Address Name of Legal Parent or Guardian of Minor Child Address Name of Horse Owner Address _________________________________________________________________________________________ Name of Person Responsible for the Horse at This Show EC # of person responsible To my HOST: QSLB Cadora and (Name of Host Facility and Owner ) Date of Show: _____________________________ and EC, OEF, Show management, the competition, officials, organisers, agents, volunteers, employees and their representatives. Each of following items must be read, understood, and initialled (if applicable) by the BOTH the COMPETITOR (or Legal Parent/Guardian of a minor child competitor) and the OWNER of the horse. 1 2 3 I am the parent and/or legal guardian of the minor child named above and am executing this form on behalf of the minor child in my capacity as parent/guardian and with the intent that this form be binding on myself and the minor child for all legal purposes. In the event that _________________________ participates in an Equine Canada sanctioned competition where protective headgear is required for juniors, he/she will wear properly fitted and fastened approved headgear at all times while riding or driving at the event location. It is understood that juniors not meeting that requirement will not be allowed to compete at these competitions. I understand there are inherent DANGERS, HAZARDS and RISKS (collectively called risks) associated with equine activities, and that injuries resulting from these risks are a common occurrence. 4 I acknowledge that the inherent risks of equine activities mean those dangerous conditions which are an integral part of equine activities, including but not limited to: - the propensity of any equine to behave in ways that might result in injury, harm or death to persons on or around them and to potentially collide with, bite or kick other animals, people or objects; - the unpredictability of an equine’s reaction to such things as sounds, sudden movement, tremors, vibrations, unfamiliar objects, person or other animals and hazards such as subsurface objects; - the potential for other participant(s) to act in a negligent manner that might contribute to injury to themselves or others, such as failing to act within their ability or to maintain control over an equine. 5 I freely accept and fully assume all responsibility for the inherent risks and the possibility of personal injury, death, property damage or loss which might result from my own/minor child’s participation. 6 I acknowledge that it remains my sole responsibility to act in such a manner as to be responsible for my own/minor child’s safety and to participate within my own/minor child’s own limits. 7 In addition for the consideration given for my/my minor child’s participation in equine activities, I and my heirs, executors, administrators and assigns (collectively called my legal representatives) agree: - to waive all claims that I might have against the HOST, - to release the HOST from any and all liability for any loss, damages, injury, or expense that I/my minor child or our legal representatives might suffer as a result of my own/minor child’s participation due to any cause including any negligence on the part of the host, - to hold harmless and indemnify the HOST from any and all liability for property damage or personal injury to my self/minor child or to any third party which might result from my own/minor child’s participation. 8 I hereby certify that every horse, rider and/or driver is eligible as entered and agree for myself and my representatives to be bound by the Constitution and Rules of Equine Canada at this competition. It is hereby recognized that all equestrian sports involve inherent risk and that no helmet or protective equipment can protect against all foreseeable injury. I hereby accept this risk and hold harmless EC, the competition, their officials, organizers, agents, employees and their representatives. 9 I hereby give authority for QSLB or its designated agent to use photographs of myself or my minor child to promote the sport of dressage on the QSLB website. Under EC rules, trainers, coaches, agents may NOT sign on behalf of the Competitor, Parent or Guardian. Signature of Competitor or Legal Parent/Guardian _________________________________________________ Signature of Horse Owner ____________________________________________________________________ Signature of Person Responsible for the Horse at This Show__________________________________________ Signed this ____ day of ________________________ 2014