Entry forms and information - Canadian Pony Club

SLOV Regional B/C Rally (July 6 th to 9 th , 2012)Application FormPart A - RegistrationRiding Team Member or Groom (circle)Name: ______________________________Pony Club Branch: ________________________Chaperone: (if applicable) ________________________________________Participant Address:_____________________________________________________________Phone/fax:___________________________Email:____________________________________Health Card Number_______________________ Allergies or other health concerns?________If yes, give details______________________________________________________________Emergency Contact______________________ (h)_________________(w)_________________Pony Club Level _____________ Age ___________ Birth Date: D____M_____Y___________Do you plan to test on the optional test day (Friday, July 6 th ): Yes No (circle)Record of Experience – Riding Participants or GroomsHow many years have you been riding? ________________ Years in Pony Club? __________Is this your first B/C Rally? ________ Have you attended a D-Level Rally previously? ____________Please specify which one (s) __________________________________________________________Have you groomed 1 at a Regional Rally in the past, if YES, which one: ____________________ ____________________________________________________________________________________For all Riders or Grooms: Confirmation of an applicant’s ‘active’ status at the Branch in 2012.(to be completed by Applicant’s Branch DC)Date: _________________________Applicant DC's Signature: __________________________ Name: _________________________Preferred Team Members (teams will be confirmed after registration is complete)1. _______________________ 3. _______________________ Groom ______________________2. _______________________ 4. _______________________ (Circle name of team captain)Part B – Program Choices – Riding ParticipantsProgramAre you applying to be included in the _____ Regular Program or _____ Advanced ProgramDressage Clinic (Optional) ___ Yes First Choice: ___ Private ($40) or ___ Semi-private ($25)Clinician: Robin Lynn Brent, Stone Meadows Farm – FEI Rider and EC High Perf. Coach-Dressage.Limited places are available and will be offered to more advanced riders and/or on a first come-firstserved basis.Part C – Record of Riding Experience – Riding ParticipantsRiding Experience – Dressage/FlatAt what level of dressage are you currently schooling ? __________ Competing ? _______________Provide a short summary of any dressage competitions you have attended with this or other mountsin the past 2 seasons ________________________________________________________________1 Groomed or volunteered at another significant Pony Club stable management activity (e.g. stable management judge or clinician; testingassistant/groom, etc.)Page 1

Riding Experience - Stadium/Over FencesAt what height are you currently schooling over fences? __________ Competing ? _______________Provide a short summary of any jumping competitions you have attended with this or other mountsin the past 2 seasons (if multiple, list 3 best results), detailing heights/levels and a brief summary ofresults (e.g. 2009 - Bronze Jumper, Ashland, 2 classes at 2'9, clear, 2 rails) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Riding Experience - Cross-CountryAt what height are you currently schooling over cross-country obstacles? ____________________Are you currently competing in Horse Trials and if so what level? ___________________________Provide a short summary of any Eventing activities or competitions you have attended with this orother mounts in the past 2 seasons (if multiple, list 3 best results, preferably with this mount),detailing level and a brief summary (e.g. 2009 - Touch, Entry, clear stadium,xc) _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Horse InformationHorse's Name:____________________________________ Size (hh): _______ Age: __________How long have this horse and rider combination been together? __________________________Is this your own horse or leased or borrowed? (circle)Horse's Eventing experience? – Level, years at that level, etc., with current or different rider?(provide details) _________________________________________________________________________________________________________________________________________________________________________________________________________________________Coaching Information - Current Coach : (to be completed by Coach)Name: __________________________ Coaching Level: ______________________________E-mail: _______________________________ Tel/Cell: _______________________________Comments on students experience in Eventing to-date: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature: ________________________________ Date: _____________________________Summary of Fees Submitted with EntryParticipation Costs (circle applicable fees) FeesRiding Regular Program Early (< 27 June) $ 260 Late (> 27 June) $ 280Participant Advanced Program Early (< 27 June) $ 280 Late (> 27 June) $ 300Groom, Chaperone or Adult Helper (staying on-site)$ 50 each (full Rally)Extra Meals (Adult Helpers, Visitors, etc.) please specify$ 10 full day; $5 /mealDressage Clinic (Optional) $ 40 (private); $25 (semi-private) – 45 min lesson(Cheques to be made out to SLOV) Total Amount IncludedPlease ensure Liability waivers are included for all participants. Cheques to be made out to SLOV.Page 2

LIABILITY WAIVERAll Participants, Chaperones, Adult Helpers, Grooms, etc. to completePlease read carefully as this document will affect your legal rights and liabilities.2012 SLOV Regional B/C RallyI realize that there are inherent dangers involved in sporting activities and that jumping in particularis a high-risk sport. I further acknowledge the inherent risk in riding and working around horses,which risks include bodily injury to both horse and rider which can result from normal use,competition or schooling. In consideration of being allowed to participate in this rally (SLOV RegionalB-C Rally at Beaulieu Farm, July 6 th to 9 th , 2012), I agree to assume all risk and responsibility for thesafety of myself, my property and my horse(s) or the horse that I am responsible for. I realize that Iparticipate at my own risk. I thereby release and absolve The Canadian Pony Club, SLOV RegionalPony Club, Beaulieu Farm, their agents and employees, the coaches, organizers, and volunteershelping to run this Rally from all responsibility, liability of claims of any kind which I may have arisingfrom participating in this Rally, including but not limited to bodily injury or death to myself or myhorse(s) and damage to property arising from any cause whatever, including the negligence of one ormore of the individuals and organizations referred to herein.Name of Participant: __________________________________________________________Please Circle: Riding participant Non-riding Groom Chaperone VolunteerSigned: ________________________________________ Date:_________________________Name of Parent: ______________________________________________________________Signed (Parent or Guardian if rider under 18 years):____________________________________Date: ______________________________(To be completed by Owner of Horse)Name of Horse: __________________________ Sex: ______ Age:_____ Colour: ____________Name of Owner of Horse: __________________________ Owner OEF # __________________Signature of Owner: ___________________________ Date: ____________________________Name of Person (on site) authorized to act in capacity of owner:__________________________________ Contact Info: ________________________________Page 1

SLOV Regional B/C Rally (July 6 th to 9 th , 2012)Chaperone or Adult Helper RegistrationName: ____________________________________________________________________Address:___________________________________________________________________Phone/fax:___________________________ Email:_________________________________Cell: __________________ Branch : ____________________________________________Chaperones:List Names & Branches of Participants for whom you are responsible (max 5)1. ________________________________________________________2. ________________________________________________________3. ________________________________________________________4. ________________________________________________________5. ________________________________________________________Adult Helpers:Please indicate what days you are available to help: ____ Fri, ____Sat, ____Sun, ____MonTeam which you are an adult helper for: ___________________________ (specify participant name)Are you planning on staying overnight any of these days? If YES, specify which days: _____________Additional meals required beyond lunch (which is free) on any days (e.g. supper) _____________ youCosts: Staying on-site, entire Rally $50 (same as chaperones); single nights $10/night; extra meals$5/each. Lunch each day is free, included. State amount of fees included in application: __________Chaperones and Adult Helpers:There will be a few key chaperone or adult helper positions that may require contributions prior toRally, or with special duties. If you would like to volunteer your time for any of these activities pleasecontact: Lori Wickert, SLOV Rally Chair, e-mail: lori.gcp.matte@rogers.com .Areas where specialized chaperone / volunteer help is required: Please check if interested:_____ First Aid Supplier (Requires at minimum valid Standard First Aid)_____ Safety Officer (helps with First Aid, required to fill forms for safety incidents)_____ Meal Planner_____ Food Purchaser/Pre-Rally Preparation_____ Kitchen Volunteer Co-ordinator / Chief Cook_____ Unmounted Activities Co-ordinator_____ Test Day Organizer_____ Stadium Jump Crew Co-ordinator (must have truck available)Other volunteer activities which are required during the weekend (please check preferred andsecond choice)_____ food preparation_____ food clean up_____ tack check_____ site cleanliness_____ stadium jump crew_____ stable management clinicTopic: (please specify) _________________________________________________________Page 1

Thank you for agreeing to be a chaperone or adult helper at the SLOV Regional B/C Rally atHawkridge Farm. Your support makes it possible for our members to take part in high quality, safeand educational activities. Without your support, it wouldn't be possible.For Chaperones Application please include (checklist): Chaperone / Adult Helper Application – e-mail or fax to B/C Rally Secretary Liability Waiver (for All Participants) – 2012 Regional B/C Rally Cheque to SLOV for $50.00 – give to Organizers or Branch Rally DelegateFor Adult Helpers Application please include (checklist): Chaperone / Adult Helper Application– e-mail or fax to B/C Rally Secretary Liability Waiver (for All Participants) – 2012 Regional B/C Rally Lunch is free each day – no charge. Cheque to SLOV for any additional costs, if applicable.For Visitors – no forms are pre-prepared, however, each must have/sign: Liability Waiver (for All Participants) – 2012 Regional B/C Rally Contribution for meals if they stay @ $5.00 each.‣ Please advise organizers in advance if there will be extra visitors and if they will join us forlunch so as we are sure to have enough for everyone.Page 2

Optional Testing Day, Friday, July 6 th , 2012 – B/C RallyTesting Registration Form(Note: Application to test information and signatures may be submitted after Rally registrationdeadline if necessary. Deadline: July 1 st , 2012, however please confirm intent to test andpreferred day as soon as possible by e-mail to Lori Wickert @ lori.gcp.matte@rogers.com).Applicants may stay over the evening prior to test day or may arrive on test day (e.g. if Test day is Friday it ispossible to arrive Thurs. If shipping in for test, stalls may also be available, please contact organizers.)PC Member to be tested:Name:__________________________________________________________________Address:________________________________________________________________Phone/fax:___________________________Email:______________________________Chaperone who will accompany PC Member: ________________________________________Health Card Number_____________________Allergies or other health concerns?___If yes, give details_________________________________________________________Emergency Contact______________________ (h)_______________(w)____________Horse's Name:____________________________________ Size (hh): _______ Age: _______How long have this horse and rider combination been together? ____________________Level to be tested: C C1 : Full test SM only Riding onlyArrival Information: Is a stall required for the night of Thursday, 5 th July: ____(Please note that you must be self-sufficient; no meals will be provided Thursday evening)________________________________________________________________________________Application to be submitted with: Testing Registration Form – e-mail or fax to B/C Rally Secretary Completed and signed C-C2 Application to Test Form (see link below) Liability Waiver (for All Participants – Testees & Chaperones) – Optional Test DayTesting costs will be payable day of test (portion of testers fee; facilities fee only if not a Rallyparticipant). Testers fees are divided amongst participants, and this portion of the testing cost couldbe as low as ~$50, or as high as $120. A minimum number of testing participants of 5 will berequired to test or testing will not go ahead (not cost effective).C-C2 Application to Test Forms available at:(http://www.canadianponyclub.org/DownloadFiles/TandE/C-C2_Test_Application_Form.pdf )Page 3

LIABILITY WAIVER for Participants & Chaperones(required only by non Rally participants)Please read carefully as this document will affect your legal rights and liabilities.Optional Testing Day – 2012I realize that there are inherent dangers involved in sporting activities and that jumping in particularis a high-risk sport. I further acknowledge the inherent risk in riding and working around horses,which risks include bodily injury to both horse and rider which can result from normal use,competition or schooling. In consideration of being allowed to participate in this test day atHawkridge Farm on either Friday, July 6 th , 2012. This liability waiver also applies to Thursday, July 7 thif PC members arrive a day early. I agree to assume all risk and responsibility for the safety of myself,my property and my horse(s) for which I am responsible. I realize that I participate at my own risk. Ithereby release and absolve The Canadian Pony Club, SLOV Regional Pony Club, Hawkridge Farm andits agents and employees, the testers, organizers, other testees and their parents and volunteershelping to run this testing day from all responsibility, liability of claims of any kind which I may havearising from participating in this test day, including but not limited to bodily injury or death to myselfor my horse(s) and damage to property arising from any cause whatever, including the negligence ofone or more of the individuals and organizations referred to herein.Name of Participant: ____________________________________________________Please Circle: Riding participant Non-riding Groom Chaperone Parent VolunteerSigned: ________________________________________ Date:________________________Name of Parent: ______________________________________________________________Signed (Parent or Guardian if rider under 18 years):_____________________________________Date: ______________________________(To be completed by Owner of Horse)Name of Horse: __________________________ Sex: ______Age:_____ Colour: __________Name of Owner of Horse: __________________________ Owner OEF # ________________Signature of Owner: ___________________________ Date: __________________________Name of Person (on site) authorized to act in capacity of owner:__________________________________ Contact Info: ______________________________Page 4