ENTRY_________________ USC HORSES AT WORK DERBY DAY ENTRY FORM Please Print Clearly, Thank You! HORSE/PONY NAME ________________________________HEIGHT_________ RIDER _____________________________________ NSEF # ________NSHJ#______ MAILING ADDRESS _______________________________________________________________________ (P.O. Box or Civic Address, City/Town, Postal Code) DATE OF BIRTH___/__/___NSEF # _______NSHJ#______ (HORSE/PONY OWNER____________________) CONTACT TELEPHONE # DAY _______________EVENING __________________CELL__________________ EMAIL: _____________________________________________________________ One entry form for each horse/rider combination. NSEF, EC Membership required(or written proof of liability insurance with $5 million coverage). Membership to the Nova Scotia Hunter Jumper Association is encouraged. Please do not arrive to compete without prior acceptance of entries-limited entry as an evening event! Div # Division Div Fee DD Derby Day $30 PLEASE READ CAREFULLY. WE THE UNDERSIGNED UNDERSTAND THAT RIDING AND CARING FOR HORSES ESPECIALLY IN A STRANGE SETTING SUCH AS A COMPETITION, CLINIC OR TRAINING EVENT IS A DANGEROUS ACTIVITY AND THAT ACCIDENTS, INCLUDING INJURY AND POSSIBLY DEATH CAN OCCUR WHEN PARTICIPATING IN THESE DANGEROUS ACTIVITIES. IT IS HEREBY RECOGNIZED THAT ALL EQUESTRIAN SPORTS INVOLVE INHERENT RISK AND THAT NO HELMET, OR PROTECTIVE EQUIPMENT CAN PROTECT AGAINST ALL FORSEEABLE INJURY. I HEREBY ACCEPT THESE RISKS AND HOLD HARMLESS USC HORSE AT WORK, THIS COMPETITION/CLINIC/EVENT, OFFICIALS, ORGANIZERS, AGENTS, EMPLOYEES, VOLUNTEERS AND THEIR REPRESENATIVES, FROM AND AGAINST ALL CLAIMS INCLUDING ANY INJURY OR LOSS SUFFERED IN CONNECTION WITH THE ABOVE NAMED EVENT, ANYWHERE ON THE GROUNDS AND SURROUNDING AREA (i.e. practice area, stable, parking area) WHETHER OR NOT SUCH CLAIM, INJURY, OR LOSS RESULTED, DIRECTLY OR INDIRECTLY, FROM THE NEGLIGENT ACTS OR OMMISSIONS OF SAID OFFICIALS, DIRECTORS, EMPLOYEES, VOLUNTEERS OR AGENTS OF USC HORSES AT WORK, OR ITS COMPETITONS OR OTHER EVENTS. IT IS UNDERSTOOD THAT ALL RIDERS WHO DO NOT WEAR A PROPERLY FITTED ASTM OR BSI APPROVED HELMET WILL NOT BE ALLOWED TO RIDE ON THE PREMISES. SIGNATURE___________________________________________________________ DATE________________________ (Parent or Guardian if under 19) PLEASE SEND ALL ENTRIES TO: USC HORSES AT WORK 44 OLD CEMETERY ROAD SWEET’S CORNER, NS, BON 2TO [email protected]