Kanopolis Challenge Entry Form

Kanopolis Challenge Entry Form
Rider______________________________________________________________JRAge_______ Address_______________________________________________________________________ Phone ___________________Emergency contact_____________________________________ Medical Info_______________________________________Phone______________________ Name of Horse________________________________________________________________ Sex________Age_______Color__________Breed____________Reg#_____________________ Owner of Horse______________________________________Phone_____________________ Address______________________________________________________________________ IAHA Qualifying Rides:__________________________________________________________ Read This Carefully Before Signing!!! I wish to participate in the above named ride. In participating I fully understand and recognize the risks and dangers involved, as well as the fact that significant unanticipated, uncontrollable and unexpected risk may arise during the ride. I agree to abide by the rules of the ride, MOTDRA and IAHA, which incorporates the rules of AERC for endurance riding, and am familiar with those rules. If I have any questions about those rules, I agree to ask ride management about them. I understand that endurance & competitive trail involves being in remote areas for extended periods of time, far from communications, transportation, and medical facilities. I recognize that ride management cannot eliminate or control all potential hazards to me or my horse or act to guarantee our safety. I know and understand that competitive or endurance riding is an inherently dangerous sporting event and agree to assume the complete risk of injury or damage which I or my horse might sustain in competing in this ride, and will hold the Kansas Department of Parks and Wildlife and everyone affiliated with the running of this ride free from liability for any injury or damage I might sustain in competing in this ride. In consideration for this agreement, ride management agrees to put on this ride in accordance with its stated rules, together with all applicable rules and guidelines of MOTDRA, IAHA, and AERC. I agree to allow and be financially responsible for any necessary emergency medical treatment by any medical institution in the event of my injury or illness. I have read and understand the rules and this liability release and agree to abide by them. Rider signature_______________________________________________Date___________ Signature of Owner___________________________________________Date____________ As a parent and/or legal guardian of the above-named junior rider, for and in consideration of this child’s participation in this ride, I agree to the terms above-stated as well on behalf of myself, my family and this child, and will hold harmless anyone so consenting. I do further authorize any officer, director, or supervisory personnel of this ride to consent in my behalf to any emergency medical treatment by a properly licensed person which may be required for my child/ward, and do agree to indemnify and hold harmless any person giving such consent. I HAVE READ AND UNDERSTOOD THIS RELEASE Signature_______________________ Relationship __________Date __________ I have agreed to SPONSOR the above-named junior and promise to abide by all the MOTDRA, IAHA and AERC rules covering the sponsor-junior relationship. Signature_____________________________________________ Proof of Coggins (dated within 12 months), Horse Registration (if applicable), AERC card, & IAHA card (if applicable) is/are required with entry.Copies of: Coggins (dated within 12 months), Horse Registration (if applicable), AERC card, & IAHA card (if applicable) is/are required with early entries***		MOTDRA Mileage: Rider______Horse______ Rider & Tack Weight _______ Rider AERC # _____________ Rider IAHA # _____________ Rider Birth Date ___________ Horse AERC # _____________ Horse IAHA#______________ Sweepstakes? Yes_____No____ Coggins Date ______________ Health Paper Date __________ Owner IAHA # ____________ Owner SS # _______________ Owner Birth Date __________ Competitive Trail SR Division Weight division ________ 15 mile - $40.00 2 day 30 mile - $60.00 40 mile open - $70.00 40 mile IAHA - $100.00 JR Division 15 mile - $35.00 2 day 30 mile - $55.00 40 mile open - $65.00 40 mile IAHA - $95.00 Endurance SR Division Weight division ________ 25 mile - $50.00 50 mile - $95.00 50 mile IAHA - $120.00 2 day 100 - $160.00 JR Division 25 mile - $45.00 50 mile - $90.00 50 mile IAHA - $115.00 2 day 100 - $155.00 *Early Entry Discount 50%* Sub-Total $_______ Non-AERC member $10.00 AERC Drug Fee - $1.00 Total $_______ Early entry discounts must be post marked by April 25, 2001 Entry fee will be refunded (less a $10 handling fee) if rider does not start.

Kanopolis Challenge Entry Form

Rider______________________________________________________________JRAge_______
Address_______________________________________________________________________
Phone ___________________Emergency contact_____________________________________
Medical Info_______________________________________Phone______________________
Name of Horse________________________________________________________________
Sex________Age_______Color__________Breed____________Reg#_____________________
Owner of Horse______________________________________Phone_____________________
Address______________________________________________________________________

IAHA Qualifying Rides:__________________________________________________________

Read This Carefully Before Signing!!! I wish to participate in the above named ride. In participating I fully understand and recognize the risks and dangers involved, as well as the fact that significant unanticipated, uncontrollable and unexpected risk may arise during the ride. I agree to abide by the rules of the ride, MOTDRA and IAHA, which incorporates the rules of AERC for endurance riding, and am familiar with those rules. If I have any questions about those rules, I agree to ask ride management about them. I understand that endurance & competitive trail involves being in remote areas for extended periods of time, far from communications, transportation, and medical facilities. I recognize that ride management cannot eliminate or control all potential hazards to me or my horse or act to guarantee our safety. I know and understand that competitive or endurance riding is an inherently dangerous sporting event and agree to assume the complete risk of injury or damage which I or my horse might sustain in competing in this ride, and will hold the Kansas Department of Parks and Wildlife and everyone affiliated with the running of this ride free from liability for any injury or damage I might sustain in competing in this ride. In consideration for this agreement, ride management agrees to put on this ride in accordance with its stated rules, together with all applicable rules and guidelines of MOTDRA, IAHA, and AERC. I agree to allow and be financially responsible for any necessary emergency medical treatment by any medical institution in the event of my injury or illness. I have read and understand the rules and this liability release and agree to abide by them.

Rider signature_______________________________________________Date___________

Signature of Owner___________________________________________Date____________
As a parent and/or legal guardian of the above-named junior rider, for and in consideration of this child’s participation in this ride, I agree to the terms above-stated as well on behalf of myself, my family and this child, and will hold harmless anyone so consenting. I do further authorize any officer, director, or supervisory personnel of this ride to consent in my behalf to any emergency medical treatment by a properly licensed person which may be required for my child/ward, and do agree to indemnify and hold harmless any person giving such consent. I HAVE READ AND UNDERSTOOD THIS RELEASE
Signature_______________________ Relationship __________Date __________
I have agreed to SPONSOR the above-named junior and promise to abide by all the MOTDRA, IAHA and AERC rules covering the sponsor-junior relationship.
Signature_____________________________________________
*Proof of Coggins (dated within 12 months), Horse Registration (if applicable), AERC card, & IAHA card (if applicable) is/are required with entry.***Copies of: Coggins (dated within 12 months), Horse Registration (if applicable), AERC card, & IAHA card (if applicable) is/are required with early entries***

MOTDRA Mileage:
Rider______Horse______
Rider & Tack Weight _______
Rider AERC # _____________
Rider IAHA # _____________
Rider Birth Date ___________
Horse AERC # _____________
Horse IAHA#______________
Sweepstakes? Yes_____No____
Coggins Date ______________
Health Paper Date __________
Owner IAHA # ____________
Owner SS # _______________
Owner Birth Date __________
Competitive Trail
SR Division
Weight division ________
15 mile - $40.00
2 day 30 mile - $60.00
40 mile open - $70.00
40 mile IAHA - $100.00
JR Division
15 mile - $35.00
2 day 30 mile - $55.00
40 mile open - $65.00
40 mile IAHA - $95.00
Endurance
SR Division
Weight division ________
25 mile - $50.00
50 mile - $95.00
50 mile IAHA - $120.00
2 day 100 - $160.00
JR Division
25 mile - $45.00
50 mile - $90.00
50 mile IAHA - $115.00
2 day 100 - $155.00
*Early Entry Discount 50%*
Sub-Total $_______
Non-AERC member $10.00
AERC Drug Fee - $1.00
Total $_______
**Early entry discounts must be post marked by April 25, 2001**
Entry fee will be refunded (less a $10 handling fee) if rider does not start.