MBRA Pointed Jackpot Entry Form 2017
SHOW ENTERED: Truro - Sept. 31st & Oct. 1st, 2017
Name:
Address
Postal Code: / Phone# / Cell#
Horses Name:
Insurance Info
Division / Class / Saturday / Sunday
SmallFry no class fee / Barrels
(ADMIN & DRUG FEE ONLY) / Poles
Dash
Pony no class fee / Barrels
(ADMIN & DRUG FEE ONLY) / Poles
Dash
Jr. Horse ($10.00) / Barrels
Youth ($5.00) / Barrels
Poles
Adult Green ($10.00) / Barrels
Poles
Novice ($10.00) / Barrels
Poles
Open ($20.00) / Barrels
Poles
3D Barrels ($15.00) ROLL OVER ( ) / Sat Only / XXXXXXXXXXX
Class Fee Total / SATURDAY / $ / SUNDAY / $
Admin Fee / $ 40.00
Drug Fee / $ 5.00
Trailer Park $20.00/per Night X ______Nights / $
Total Fee / SATURDAY / $ / SUNDAY / $
Forward Entry form to: Heather Strickland
116 Henley Road, Chelsea, NS B4V 7N3 / TOTAL FEE PAID $______
Fax 902-634-3203 Phone 902-685-2014 Cell 902-298-2270
Email entries:
Entries may be paid by: etransfer to or cash only at show office
Etransfers will ONLY be ACCEPTED until Wednesday Sept. 27th
**ALL COMPLETE ENTRIES MUST BE IN BY 8pm Sept, 29th**
Forever Memories Equestrian Centre
WAIVERANDRELEASEOFLIABILITY
InconsiderationofbeingallowedtoparticipateinanywayinaMaritimeBarrelRacingAssociationsanctioned event,andinparticulartheJackpot/Show beingknownasForever Memories Equestrian Centre - MBRA.Pointed Jackpot, @ Nova Scotia Provincial Exhibition Grounds, Truro, NS – Sept. 30th & Oct. 1st, 2017.
aswellasanyandallactivitiesrelatedtosuchevent,theundersignedacknowledges,appreciatesandagreesthat
1. Theriskofinjuryfromtheactivitiesinvolvedinthistypeofeventissignificant,includingthepotentialfor permanentparalysisanddeath,andwhileparticularrules,equipmentandpersonaldisciplinemayreducethisrisk, theriskofseriousinjurydoesexistand
2. IKNOWINGLY ANDFREELYASSUMEALLSUCHRISKS,bothknownandunknown,EVENIFARISING FROMTHENEGLIGENCE OFTHERELEASEESorothers,andassumefullresponsibilityformyparticipation and
3. Iwillinglyagreetocomplywiththestatedandcustomarytermsandconditionsforparticipationin thisevent. If howeverIobserveanyunusualsignificanthazardduringmypresenceorparticipation,Iwillremovemyselffrom participationandbringsuchtotheattentionofthenearestofficialimmediatelyand
4. I, formyselfandonbehalfofmyheirs,assigns,personalrepresentativesand nextofkin,HEREBYRELEASE ANDHOLDHARMLESS theForever Memories Equestrian Centre and the MaritimeBarrelRacingAssociation,theirofficers,officials,agentsand/or employees,otherparticipants,sponsoringagencies,sponsors,advertisers,and, ifapplicable,ownersandlessorsof premisesusedtoconducttheevent("Releasees"),WITHRESPECTTOANYANDALLINJURYDISABILITY, DEATH,orlossordamagetopersonorproperty,WHETHERCAUSEDBYTHENEGLIGENCEOFTHE RELEASEESOROTHERWISE.
5.Iagreetoabidebyallof therules,regulations,andpoliciesoftheMaritimeBarrelRacingAssociationwhile participatingatthisevent.
IHAVEREADTHISRELEASEOFLIABILITY ANDASSUMPTION OFRISKAGREEMENT,FULLY UNDERSTANDITSTERMS,UNDERSTAND THATIHAVEGIVENUPSUBSTANTIALRIGHTSBY SIGNINGITANDSIGNITFREELYANDVOLUNTARILY WITHOUTANYINDUCEMENT.
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PARTICAPANT’S SIGNATURE
X______Date Signed ______
PRINT NAME
FORPARTICIPANTS OFMINORITY AGE (UNDERAGEATTHETIMEOFREGISTRATION)
ThisistocertifythatI,asparent/guardian withlegalresponsibilityforthisparticipant,doconsentandagreeto his/herreleaseasprovidedaboveofallReleasees,and,formyself,myheirs,assigns,andnextofkin,IreleaseandagreetoindemnifytheReleaseesfromanyandallliabilitiesincidenttomyminorchild’s involvementorparticipationintheseprogramsasprovidedabove,
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PARENT/GUARDIAN’S SIGNATURE EMERGENCY PHONE NUMBER
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PRINT NAMENAME OF MINOR (please print)