Fill and Sign the Cayman First Insurance Forms

2011 DRESSAGE COMPETITION ENTRY FORM Effective December 1, 2010, use this form for entering USEF/USDF Licensed Dressage Competitions held in USDF Region 1 (PA, NJ, DE, MD, VA, NC, WV) Competitors are responsible for duplicating their own additional copies of this entry form. This is a 2-sided form; please make 2-sided copies. Other versions of entry forms may not be accepted by Region 1 competitions. TYPE OR PRINT CLEARLY -- ONLY ONE HORSE / RIDER or HANDLER PER ENTRY FORM Official Use Only Bridle No. Enclose copy of all 2011 USEF Membership Cards (Rider/Handler, Owner/Agent, Trainer, Coach) or verification. Competition Name: _____________________________________________ NAME OF HORSE (Horse MUST be named) Date of Coggins (must attach copy): Sire: BREED Competition Date(s): COUNTRY (Where Bred) SEX HEIGHT Breed Registration Number: Dam: For Dressage Sport Horse Breeding (DSHB) classes, Sire, Dam, Dam’s Sire & Breeder names required for ALL breed registered horses & recommended for others. ________________ COLOR AGE DOB Check here If this horse is for sale and you want this to be listed in the Program _____ Dam’s Sire: Breeder: Rider/Handler: __________________________________ Primary Phone: _______________Alternate Phone: _______________ Rider’s Address: _________________________________________________________________________________________ Rider/Handler E-Mail: _____________________________________________________________Citizenship*: ______________ Owner: _____________________________________ Primary Phone: ________________Alternate Phone: _________________ Owner’s Address: __________________________________________________________E-Mail: ________________________ Trainer: ______________________________ Trainer’s Address:___________________________________________________ Coach: _______________________________ Trainer’s Phone during Competition: ____________________________________ HORSE RIDER/HANDLER OWNER (At least one) USEF# USEF# USEF# USDF# USDF# TRAINER COACH (if applicable) USDF# LOCAL ASSN # Unless show provides entry verification service: * MUST attach copies of USEF & USDF Horse Recording and Registration Certificates for GAIG/USDF Qualifying and Championship Classes. * MUST include a copy of USEF Amateur Certification if competing as an Adult Amateur. Go to http://www.eqverification.org/ to print copies. Class # Day USEF# USEF# All USEF members (including riders, handlers, trainers, coaches, owners, agents or lessees) are required to submit proper membership documentation to the show secretary prior to competing. Exhibitors who do not send a copy of their card with their entry or are unable to produce the card when registering at the competition, or for whom the competition cannot verify such information (with the exception of Federation measurement cards) will be required to pay a $30 non-member fee which is non-refundable. EACH Junior and Senior participant (rider, handler, trainer, coach and one owner/agent per horse) is required to be a USEF Active “Competing” Member or pay a $30 non-member fee (see the official USEF nonmember Statement in prize list). Non-U.S. citizen participants in Dressage/DSHB classes MUST attach current proof, in English, of current membership in good standing in their own N.F in order to be exempt from USEF non-member fees. Class Name (Level//Division/Test – if TOC) GAIG Fee Fee Payment For Subtotal, Class Fees USEF Non-Member Fee(s) ($30 per participant) USEF Fee per horse: (D&M $7 + USEF $8) = $15 CDI horses only: USEF Fee per horse: (D&M $15 + USEF $8) = $23 CDIs only: USEF IHP Discipline Fee ($35 per entry) Stabling / Grounds Fee (For NonStabled Horses) USDF Non-Member Fee(s) ($25 per rider/owner) Office Fee SUBTOTAL Class Fees JR or YR Birthdate: _________________________ Riders are eligible to compete as a Jr/YR until the end of the calendar year in which they reach the age of 21 Late Fee, Bridle Number Fee, Camper Fee Other Fee(s) TOTAL FEES DUE: CDI / CDI-Y/ CDI-J/ CDI-P COMPETITORS MUST COMPLETE THE FOLLOWING INFORMATION: Rider: Citizenship: FEI Rider Registration #: Competing for Country: Horse: Present Nationality: Birthdate: Previous Name (if any): FEI Horse Registration #: Person Responsible: FEI Passport #: Owner: Citizenship: Owner Social Security or Tax ID # (required to receive prize money): Fee Office Use US Equestrian Federation, Inc. Entry Agreement I have read the United States Equestrian Federation, Inc. (the “Federation”) Entry Agreement (GR906.4) as printed in the Prize List for [insert name here] (“Competition”) and agree to all of its provisions. I understand and agree that by entering this Competition, I am subject to Federation Rules, the Prize List, and local rules of the competition. I agree to waive the right to the use of my photos from the competition, and agree that any actions against the Federation must be brought in New York State. 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. *RIDER/HANDLER (mandatory) *OWNER / AGENT (mandatory) *TRAINER (mandatory) COACH (If applicable) Signature: Signature: Signature (must be 18 or older): Signature: Print: Print: Print: Print: PARENT/GUARDIAN (Required if rider/handler is a minor, i.e. under 18) Signature: Home Emergency Phone Contact # Is RIDER a U.S. citizen? (mandatory) Print: YES ________ NO ________ * No entry is valid without original signatures from the above individuals; Photocopied signatures or writing “same” are NOT acceptable. STABLING / CAMPER HOOK-UP RESERVATION FORM (Refer to Prize List for Specifications) ENTRY PREPARATION CHECKLIST Contact NAME and NUMBER for Rider Emergency: Contact NAME and NUMBER for Horse Emergency: ____________________/______________________ __________________/_______________________ ___________________________________________ Name of Lodgings Where Rider or Responsible Party Will be Staying During the Competition _________________________________________ Hotel Number at the Competition (For Emergency Contact Purposes) Stall Occupant Sex (S,M,G) Check Stall Days/Nights Desired (see prize list directives) Mon Tues Wed Thurs Fri Sat Sun Horse Name If accompanied by NON-COMPETING HORSE, must complete separate entry form and pay all applicable fees. Tack n/a Approx. Time of Arrival: Special Requests*: __________________ Approx. Time of Departure: __________________ ____________________________________________________________________ _______________________________________________________________________________________ *Provide name of individual with whom you desire to be stabled (if part of a group, make sure you all name the same person) Stabling fees: ___________stalls for ___________nights @ $ _________ per night = __________________ Camper fees _____hook-ups @ $______ea (flat rate) OR _____nights @ $ _______ per night = _________ TOTAL STABLING / CAMPER HOOK-UP FEES: _________________ Before Mailing, Be Sure You Have: ___Completed Both Sides of Entry Form ___ All Original Required Signatures ___ Enclosed a Copy of the Current Negative Coggins (EIA) Certificate (Refer to the Competition Specifications for date validity requirements.) Copy must be legible. ___ Supplied all Required Ass’n Numbers ___ Enclosed Copies of Applicable USEF and/or USDF Cards or Documents ___ Completed the Stabling / Camper Reservation Form ___ Enclosed a Check / Money Order for all Applicable Fees. ___Attached photocopy of Test(s) verifying USDF & FEI Freestyle Test eligibility (ex. for exempt classes) Mail this Entry Form, Supplemental Documents, and Fees to the Competition (Entry) Secretary Identified on the Prize List. RIDER / TRAINER EMERGENCY CELL PHONE CONTACT NUMBER AT COMPETITION: ________________________________ PLEASE SUBMIT ANY IMPORTANT INFORMATION FOR THE ANNOUNCER ON A SEPARATE SHEET