Northern District Qualifying & Open Show Fauquier County, VA Saturday, May 21, 2016 9:00 AM Hosted by: Blazing Saddles 4-H Club Warrenton Horse Show Grounds 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.

JR – Western Pleasure, Walk/Jog JR – Western Pleasure, Go-as-you-Please JR – Western Pleasure, Walk/Jog/Lope SR – Western Pleasure, Walk/Jog SR – Western Pleasure, Go-as-you-Please SR – Western Pleasure, Walk/Jog/Lope SR/JR Driving, Pleasure SR/JR Driving, Reinsmanship SR/JR Driving, Super Reinsmanship JR – Hunter Pleasure Pony, Walk/Trot JR – Hunter Pleasure Pony, Walk/Trot/Canter JR – Hunter Pleasure Pony, Go-as-you-Please SR – Hunter Pleasure Pony, Walk/Trot SR – Hunter Pleasure Pony, Walk/Trot/Canter SR – Hunter Pleasure Pony, Go-as-you-Please JR – Hunter Pleasure Horse, Walk/Trot JR – Hunter Pleasure Horse, Walk/Trot/Canter JR – Hunter Pleasure Horse, Go-as-you-Please SR – Hunter Pleasure Horse, Walk/Trot SR – Hunter Pleasure Horse, Walk/Trot/Canter SR – Hunter Pleasure Horse, Go-as-you-Please JR – Horse/Pony Hunter Over Fences 2’ JR – Horse/Pony Hunter Over Fences 2’ JR – Horse/Pony Hunter Under Saddle SR – Horse/Pony Hunter Over Fences 2’ SR – Horse/Pony Hunter Over Fences 2’ SR – Horse/Pony Hunter Under Saddle JR – Horse/Pony Hunter Over Fences 2’6” JR – Horse/Pony Hunter Over Fences 2’6” JR – Horse/Pony Hunter Under Saddle SR – Horse/Pony Hunter Over Fences 2’6” SR – Horse/Pony Hunter Over Fences 2’6” SR – Horse/Pony Hunter Under Saddle

Pre-registration is encouraged as entries will be limited. Pre-register $10.00 per class or $45.00 All Day Per Horse/Rider Combo (Available for preentries only) Entry fees day of show $12.00 per class. 4-H -MANDATORY $5.00 Northern District Council show fee required for each horse/rider combination. To pre-register, mail to: Kim Abel 3510 Rock Run Road Goldvein, VA 22720 Or email to: [email protected] Pre-entries must be received by May 16th. 4-H Members must also include copy of measurement cards. Divisions: JR – Western Pleasure SR – Western Pleasure Driving JR – Hunter Pleasure, Pony SR – Hunter Pleasure, Pony JR – Hunter Pleasure, Horse SR – Hunter Pleasure, Horse JR – Horse/Pony O/F 2’ SR – Horse/Pony O/F 2’ JR – Horse/Pony O/F 2’6” SR – Horse/Pony O/F 2’6” There will be NO food available on the grounds.

NO.

Pre-Entry

Northern District 4-H Qualifying & Open Show Registration Form PART I - EXHIBITOR INFORMATION (One form per horse/rider combo) Name of Exhibitor Address ______________________________________ City___________________ ZIP____________ Birth Date of Exhibitor

SR or JR (circle one)

District Qualifier: Yes or No (circle one)

Phone Number

County/Club

Name of Horse

Horse or Pony (circle one): Height

DIVISIONS/CLASSES (Circle all classes you wish to enter. If you pre-enter and need to add more classes at the show you may do so at the pre-entry price: Day Fee ______________ JR-Western Pleasure SR-Western Pleasure Driving JR-Hunter Pleasure Pony SR-Hunter Pleasure Pony

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

JR-Hunter Pleasure Horse 16 17 18 Pre-Entry_____________ SR-Hunter Pleasure Horse 19 20 21 JR-Horse/Pony 2 Ft 22 23 24 Total Classes__________ SR-Horse/Pony 2 Ft 25 26 27 JR-Horse/Pony 2’6 28 29 30 Amount paid__________ SR-Horse/Pony 2’6 31 32 33 FEES (Please make checks payable to Treasurer of Virginia Tech – In Note Field: Fauquier District Horse Show Pre-register $45 Day fee Per Horse/Rider combo or $10.00 per class Horse/Rider combo OR Day of show $12 per class 4-H Northern District fee: $5.00 (Mandatory for all 4H Members)

SIGNATURES WAIVER AND ACKNOWLEDGMENT OF ASSUMPTION OF RISK I, AS A PARTICIPANT, AND/OR THE PARENT OR GUARDIAN OF THE PARTICIPANT, IN KEEPING WITH THE VIRGINIA EQUINE LIABILITY ACT, VA. CODE #E.1-796.130, ET SEQ (1991 CUM. SUPP.), HEREBY WAIVE THE RIGHTS OF THE PARTICIPANT AND THE PARENT, GUARDIAN OR NEXT FRIEND OF THE PARTICIPANT, TO SUE THE BLAZING SADDLES 4-H, WARRENTON SHOW GROUNDS, THE EQUINE ACTIVITY SPONSORS AND THE EQUINE PROFESSIONALS FOR DAMAGES RESULTING FROM THE INJURY OR DEATH OF THE PARTICIPANT ENGAGED IN THE EQUINE ACTIVITY DESCRIBED AS NORTHERN DISTRICT HORSE SHOW TO BE HELD AT THE WARRENTON HORSE SHOW GROUNDS, WARRENTON, VA. ON MAY 21, 2016. I ACKNOWLEDGE THAT BOTH THE PARTICIPANT AND, IF THIS DOCUMENT IS BEING EXECUTED BY THE PARENT OR LEGAL GUARDIAN OF THE PARTICIPANT, THE PARENT OR LEGAL GUARDIAN OF THE PARTICIPANT, HAS BEEN NOTIFIED AND IS FULLY AWARE OF THE RISKS INHERENT IN EQUINE ACTIVITIES INCLUDING: (i) THE PROPENSITY OF AN EQUINE TO BEHAVE IN DANGEROUS WAYS WHICH MAY RESULT IN HARM TO THE PARTICIPANT: (ii) THE INABILITY TO PREDICT AN EQUINE’S REACTION TO SOUND, MOVEMENTS, OBJECTS, PERSONS, OR ANIMALS, AND (iii) HAZARDS OF SURFACE OR SUBSURFACE CONDITIONS. I, AS THE PARTICIPANT, AND/OR THE PARENT OR GUARDIAN OF THE PARTICIPANT EXPRESSLY ASSUME THE RISKS DESCRIBED ABOVE AND FURTHER ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO INVESTIGATE AND BECOME FAMILIAR WITH THE PROPENSITIES OF THE EQUINE I WILL BE RIDING AND THE SURFACE OR SUBSURFACE CONDITIONS UPON WHICH I WILL BE RIDING.I CERTIFY THAT I HAVE READ THE FOREGOING DOCUMENT AND UNDERSTAND ITS CONTENTS NOTE: FOR ALL PARTICIPANTS UNDER THE AGE OF 19 AS OF THE DATE OF THIS EVENT, THIS WAIVER AND ACKNOWLEDGMENT OF ASSUMPTION OF RISK, MUST BE SIGNED BY THE PARENT OR LEGAL GUARDIAN OF THE UNDERAGE PARTICIPANT.

PARTICIPANT (PRINTED) _____________________________________ SIGNATURE PARENT/GUARDIAN (PRINTED) _______________________________ SIGNATURE

Bring with you to the show in order to receive your show number: CHECK FOR FEES and COPY OF CURRENT COGGINS All pre-registered must be received by May 16th, no exceptions!! Email Forms to: [email protected] OR

Mail or hand deliver to: Kim Abel 3510 Rock Run Road Goldvein, VA 22720