Pacific Barrel Horse Association

Entry Form

BRN4D #______________

Name_____________________________________________________ CWP # ______________

NW5D # ______________

Address________________________City___________St_______Zip__________

Phone____________________email____________________________________SSI Number_______________________

1^st Horse_______________________ 2^nd Horse________________________

Class
Open Barrels	$15.00	$15.00
Sidepot	$25.00	$25.00
BRN4D qualifying fee	$2.00	$2.00
CWP	$1.00	$1.00
NW5D	$2.00	$2.00
Youth Barrels (18 & under)	$7.00        Roll             Run	$7.00        Roll             Run
BRN4D Youth qualifying fee	$2.00	$2.00
CWP	$1.00	$1.00
NW5D	$2.00	$2.00
Senior Barrels (45 & over)	$7.00       Roll               Run	$7.00       Roll               Run
BRN4D Senior qualifying fee	$2.00	$2.00
CWP	$1.00	$1.00
Buckaroo Barrels	$2.00	$2.00
Medals Class	$10.00      Roll              Run	$10.00      Roll              Run
Open Poles	$7.00	$7.00
Buckaroo Poles	$2.00	$2.00
Membership	$20.00	$20.00
Family Membership	$30.00	$30.00
Award fee per horse	$20.00	$20.00
Time Runs (1 time)	$3.00 (Buy at the gate please)	$3.00 (Buy at the gate please)
Stalls	$15.00  Trails & Stewarts	$15.00   Trails & Stewarts
RV Hook ups	$15.00    Trails only	$15.00    Trails only
Office Charge Additional Horse fee	$7.00 $5.00 per horse	$7.00 $5.00 per horse
	Total	Total

I do hereby declare that I am a participant or legal custodial parent of guardian of my child or ward participating in this event. I hereby agree to comply with all rules and regulations of the arena, producers and sponsors. For myself, my executors, heirs, next of kin, administrators, successors and assigns, I hereby waive and release all claims that I may have against the Pacific Barrel Horse Association and co-sanctioning organizations, it’s officers, members, volunteers, sponsors, facility owners including any and all claims for damage caused by negligence of any of them, arising out of my participation in this event and it’s related activities. I further agree to indemnify, release, hold harmless and defend the Pacific Barrel Horse Association and co-sanctioning organizations, its officers, volunteers, sponsors and arena owners against any and all claims of injury or damage to persons or property. I understand that horses and activities involving horses can cause serious injury or death. I hereby acknowledge that participation in this event carries potential hazard, I therefore release the Pacific Barrel Horse Association and co-sanctioning organizations, its officers, members, volunteers, sponsors and facility owners of any liability resulting from injury or death during this event or related activity. This release is perpetual for the 2009 season ending 12/31/09.

Signed______________________________________________________Date_______________________

(Any one under 18 must have a parent or legal guardian sign)

Signature of Parent or legal guardian______________________________Date_______________________