Main Entry Blank.indd
HAMPTON CLASSIC HORSE SHOW - August 27 - September 3, 2017 Entries close Friday, July 21, 2017. All received after 6:00 p.m. will be considered late.
No entries will be accepted by fax and we cannot provide confirmation of receipt. Exhibitors must have current USEF/USHJA membership card available or a copy sent with entry.
HORSE NAME HORSE / USEF / EC #
RIDER ONE
RIDERS
USEF/USHJA#
ASPCA#
EC#
CIRCLE JR
CLASSES
RIDER ONE CLASSES
AM PRO COLOR
SEX
HEIGHT
AGE
FEI PASSPORT #
HORSE/PONY Small
BREED
DOB
BIRTH CTRY STUD BK
Medium 1
GREEN YEAR
RIDER TWO
JR
Large 2
OWNER OR AUTHORIZED AGENT
PRO
RIDER ONE
NAME
NAME
ADDRESS
ADDRESS
BARN NAME
CITY/STATE/ZIP
CITY/STATE/ZIP
ADDRESS
TELEPHONE
USEF/USHJA/EC #
EMAIL
DOB M/D/Y
TELEPHONE
RIDER TWO CLASSES
AM
GENDER
USEF/USHJA/FEI #
TRAINER
STABLE WITH (BARN NAME)
NAME
USEF/USHJA/FEI FEES USHJA Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $7
CITY/STATE/ZIP
USEF Drugs/Medications Fee ������������������������������$8
EMAIL
TELEPHONE
RECIPIENT OF PRIZE MONEY AWARDS NAME
NAME
ADDRESS
ADDRESS
CITY/STATE/ZIP
CITY/STATE/ZIP
TELEPHONE
TELEPHONE
SS# or FED ID#
EMAIL
USEF/USHJA/EC #
USEF Federation Fee. . . . . . . . . . . . . . . . . . . . . . $8 USEF Show Pass Fee. . . . . . . . . . . . . . . . . . . . . . $30
RIDER TWO DOB M/D/Y
USEF/USHJA/FEI #
GENDER
EMAIL
USHJA Show Pass Fee . . . . . . . . . . . . . . . . . . . . $30
CANADIAN EXHIBITORS: CHECK MUST BE PRE-PRINTED "U.S. FUNDS"
All checks payable to: Hampton Classic Horse Show P.O. Box 3013 240 Snake Hollow Rd. Bridgehampton, NY 11932 (631) 537-3177
UNITED STATES 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 Hampton Classic (“Competi-
FEI Horse Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $33 USEF IHP Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $35
FEES
Entry Fee. . . . . . . . . . . . . . . . . . . . . . . . . Nominating Fee ($200). . . . . . . . . . . . . . Back of Grounds Stall Fee ($250). . . . . .
tion”) 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 Front of Grounds Stall Fee ($350). . . . . 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 FEI Horse Stall Fee ($350). . . . . . . . . . . York State. Federation Release, Assumption of Risk, Waiver and Indemnification Stabled Horse Deposit ($100). . . . . . . . This document waives important legal rights. Read it carefully before signing. $15 I AGREE in consideration for my participation in this Competition, Hampton Classic Horse Show to the following: Competition and to hold them harmless with respect to claims for Harm to me or my horse, and for claims Equine Ambulance Fee. . . . . . . . . . . . . . I AGREE that the “Federation” and “Competition” as used above includes all of their officials, officers, made by others for any Harm caused by me or my horse while at the Competition. I have read the Federation $50 Rules about protective equipment, including GR801 and, if applicable, EV114, and I understand that I am entitled Office Fee. . . . . . . . . . . . . . . . . . . . . . . . directors,employees, agents, personnel, volunteers and affiliated organizations. I AGREE that I choose to participate voluntarily in the Competition with my horse, as a rider, driver, handler, to wear protective equipment without penalty, and I acknowledge that the Federation strongly encourages me AMOUNT ENCLOSED $ vaulter, longeur, lessee, owner, agent, coach, trainer, or as parent or guardian of a junior exhibitor. I am fully to do so while WARNING that no protective equipment can guard against all injuries. If I am a parent or aware and acknowledge that horse sports and the Competition involve inherent dangerous risks of accident, guardian of a junior exhibitor, I consent to the child’s participation and AGREE to all of the above provisions OFFICE USE ONLY loss, and serious bodily injury including broken bones, head injuries, trauma, pain, suffering, or death. (“Harm”). and AGREE to assume all of the obligations of this Release on the child’s behalf I represent that I have the CK# _________ CK AMT $__________ I AGREE to hold harmless and release the Federation and the Competition from all claims for money damages requisite training, coaching and abilities to safely compete in this competition. or otherwise for any Harm to me or my horse and for any Harm of any nature caused by me or my horse I AGREE that if I am injured at this competition, the medical personnel treating my injuries may provide ____________________________ to others, even if the Harm arises or results, directly or indirectly, from the negligence of the Federation or information on my injury and treatment to the Federation on the official USEF accident/injury report form. Requirements met and eligible for VIP table drawing BY SIGNING BELOW, I AGREE to be bound by all applicable Federation Rules and all terms and provisions the Competition. of this entry blank and all terms and provisions of this Prize List. If I am signing and submitting this Agreement I AGREE to expressly assume all risks of Harm to me or my horse, including Harm resulting from the negliAMERICAN EXPRESS PAYMENT electronically, I acknowledge that my electronic signature shall have the same validity, force and effect as if I gence of the Federation or the Competition. AMEX # I AGREE to indemnify (that is, to pay any losses, damages, or costs incurred by) the Federation and the affixed my signature by my own hand.
MANDATORY
OWNER/AGENT SIGNATURE: SIGNATURE: Print Name: Print Name: (Required if Rider/Handler is a minor)
PARENT/GUARDIAN SIGNATURE: Print Name: EMERGENCY CONTACT PHONE #
RIDER/HANDLER
Is Rider a U.S. Citizen: YES NO
SIGNATURE: Print Name:
Is Rider a U.S. Citizen: YES NO
SIGNATURE: Print Name: COACH SIGNATURE: (if applicable)
Print Name:
TRAINER
Name on card Signature Exp Date
/ CCV #
I authorize the Hampton Classic Horse Show, Inc. to charge my card for all amounts due, with respect to this entry form.
No entries will be accepted by fax and we cannot provide confirmation of receipt. Exhibitors must have current USEF/USHJA membership card available or a copy sent with entry.
HORSE NAME HORSE / USEF / EC #
RIDER ONE
RIDERS
USEF/USHJA#
ASPCA#
EC#
CIRCLE JR
CLASSES
RIDER ONE CLASSES
AM PRO COLOR
SEX
HEIGHT
AGE
FEI PASSPORT #
HORSE/PONY Small
BREED
DOB
BIRTH CTRY STUD BK
Medium 1
GREEN YEAR
RIDER TWO
JR
Large 2
OWNER OR AUTHORIZED AGENT
PRO
RIDER ONE
NAME
NAME
ADDRESS
ADDRESS
BARN NAME
CITY/STATE/ZIP
CITY/STATE/ZIP
ADDRESS
TELEPHONE
USEF/USHJA/EC #
DOB M/D/Y
TELEPHONE
RIDER TWO CLASSES
AM
GENDER
USEF/USHJA/FEI #
TRAINER
STABLE WITH (BARN NAME)
NAME
USEF/USHJA/FEI FEES USHJA Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $7
CITY/STATE/ZIP
USEF Drugs/Medications Fee ������������������������������$8
TELEPHONE
RECIPIENT OF PRIZE MONEY AWARDS NAME
NAME
ADDRESS
ADDRESS
CITY/STATE/ZIP
CITY/STATE/ZIP
TELEPHONE
TELEPHONE
SS# or FED ID#
USEF/USHJA/EC #
USEF Federation Fee. . . . . . . . . . . . . . . . . . . . . . $8 USEF Show Pass Fee. . . . . . . . . . . . . . . . . . . . . . $30
RIDER TWO DOB M/D/Y
USEF/USHJA/FEI #
GENDER
USHJA Show Pass Fee . . . . . . . . . . . . . . . . . . . . $30
CANADIAN EXHIBITORS: CHECK MUST BE PRE-PRINTED "U.S. FUNDS"
All checks payable to: Hampton Classic Horse Show P.O. Box 3013 240 Snake Hollow Rd. Bridgehampton, NY 11932 (631) 537-3177
UNITED STATES 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 Hampton Classic (“Competi-
FEI Horse Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $33 USEF IHP Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . $35
FEES
Entry Fee. . . . . . . . . . . . . . . . . . . . . . . . . Nominating Fee ($200). . . . . . . . . . . . . . Back of Grounds Stall Fee ($250). . . . . .
tion”) 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 Front of Grounds Stall Fee ($350). . . . . 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 FEI Horse Stall Fee ($350). . . . . . . . . . . York State. Federation Release, Assumption of Risk, Waiver and Indemnification Stabled Horse Deposit ($100). . . . . . . . This document waives important legal rights. Read it carefully before signing. $15 I AGREE in consideration for my participation in this Competition, Hampton Classic Horse Show to the following: Competition and to hold them harmless with respect to claims for Harm to me or my horse, and for claims Equine Ambulance Fee. . . . . . . . . . . . . . I AGREE that the “Federation” and “Competition” as used above includes all of their officials, officers, made by others for any Harm caused by me or my horse while at the Competition. I have read the Federation $50 Rules about protective equipment, including GR801 and, if applicable, EV114, and I understand that I am entitled Office Fee. . . . . . . . . . . . . . . . . . . . . . . . directors,employees, agents, personnel, volunteers and affiliated organizations. I AGREE that I choose to participate voluntarily in the Competition with my horse, as a rider, driver, handler, to wear protective equipment without penalty, and I acknowledge that the Federation strongly encourages me AMOUNT ENCLOSED $ vaulter, longeur, lessee, owner, agent, coach, trainer, or as parent or guardian of a junior exhibitor. I am fully to do so while WARNING that no protective equipment can guard against all injuries. If I am a parent or aware and acknowledge that horse sports and the Competition involve inherent dangerous risks of accident, guardian of a junior exhibitor, I consent to the child’s participation and AGREE to all of the above provisions OFFICE USE ONLY loss, and serious bodily injury including broken bones, head injuries, trauma, pain, suffering, or death. (“Harm”). and AGREE to assume all of the obligations of this Release on the child’s behalf I represent that I have the CK# _________ CK AMT $__________ I AGREE to hold harmless and release the Federation and the Competition from all claims for money damages requisite training, coaching and abilities to safely compete in this competition. or otherwise for any Harm to me or my horse and for any Harm of any nature caused by me or my horse I AGREE that if I am injured at this competition, the medical personnel treating my injuries may provide ____________________________ to others, even if the Harm arises or results, directly or indirectly, from the negligence of the Federation or information on my injury and treatment to the Federation on the official USEF accident/injury report form. Requirements met and eligible for VIP table drawing BY SIGNING BELOW, I AGREE to be bound by all applicable Federation Rules and all terms and provisions the Competition. of this entry blank and all terms and provisions of this Prize List. If I am signing and submitting this Agreement I AGREE to expressly assume all risks of Harm to me or my horse, including Harm resulting from the negliAMERICAN EXPRESS PAYMENT electronically, I acknowledge that my electronic signature shall have the same validity, force and effect as if I gence of the Federation or the Competition. AMEX # I AGREE to indemnify (that is, to pay any losses, damages, or costs incurred by) the Federation and the affixed my signature by my own hand.
MANDATORY
OWNER/AGENT SIGNATURE: SIGNATURE: Print Name: Print Name: (Required if Rider/Handler is a minor)
PARENT/GUARDIAN SIGNATURE: Print Name: EMERGENCY CONTACT PHONE #
RIDER/HANDLER
Is Rider a U.S. Citizen: YES NO
SIGNATURE: Print Name:
Is Rider a U.S. Citizen: YES NO
SIGNATURE: Print Name: COACH SIGNATURE: (if applicable)
Print Name:
TRAINER
Name on card Signature Exp Date
/ CCV #
I authorize the Hampton Classic Horse Show, Inc. to charge my card for all amounts due, with respect to this entry form.
