Entry for Pumpkin Derby

SHOW DATE: October 8, 2022 --- CLOSING DATE for entries: Thursday, October 5, 2022

Show Secretary: April Haynos
akrenz51@gmail.com
8477 Baker Rd
Bloomfield, NY 14469

Location: Hideaway Farm, 4130 Roots Tavern Rd, Geneseo, NY

Entry Fees: by closing date -$30/class for GVRDC members - $40/class for non-members
Post Entry: (on day of Derby) $60/class GVRDC members, $70/class non-member
NOTE: Entries made by closing date can add classes on the day of Derby at $40/class

Incomplete entries will NOT be accepted. NO PHONE entries! No dogs allowed on show grounds.

Minors under 18 must be accompanied by parent or guardian.
ASTM/SEI Certified Helmets and Safety Vests are REQUIRED while mounted!
Medical armbands are recommended.

Ride times available at www.gvrdc.org

Please use a separate form for each horse. Ribbons will be given for 1st - 6th place.

IMPORTANT: Using the on-line form for entry and payment
Fill out all information on Entry Form, upload your Coggins, and click on the CONTINUE button to review your entry. Click on SUBMIT to go to the GVRDC PayPal account where you can pay by credit card or with your PayPal account. If NOT paying on-line, check the $0.00 fees box, click CONTINUE and SUBMIT. You will be sent an email with your Entry as an attachment. Print it and send in with your check to the show secretary listed above.
Rider Info:
Rider
GVRDC/USPC Member

GVRDC/USPC Member Yes No
Street Address
City, State, Zip
Phone
Email

Make sure there are no typos in your email address
Horse Info:
Horse's Name
Age
Name on Coggins
Coggins Test
Upload Coggins (must be current within 2 years of show date)

Attach Files

Choose the file on your computer that is the Coggins test result for your horse. It can be a jpg, doc or pdf file. Mail to show secretary if you don't upload it.

Indicate the divisions you are entering. You may enter 2 classes in one division, but 1 class must be "open" and the other "horse" or "rider". Or you can enter 2 different divisions if the lower level is "open" and the upper level is "horse" or "rider".
	Horse	Rider	Open
Intro	IntroHorse	IntroRider	IntroOpen
Beginner Novice A	Beginner Novice AHorse	Beginner Novice ARider	Beginner Novice AOpen
Beginner Novice B	Beginner Novice BHorse	Beginner Novice BRider	Beginner Novice BOpen
Novice	NoviceHorse	NoviceRider	NoviceOpen
Training	TrainingHorse	TrainingRider	TrainingOpen
Tr/Prelim (need at least 3 entries)	Tr/Prelim (need at least 3 entries)Horse	Tr/Prelim (need at least 3 entries)Rider	Tr/Prelim (need at least 3 entries)Open

Fees Due when paid by closing date

Fees Due when paid by closing date $30 1 class (member Entry Derby) $60 2 classes (member Entry Derby) $40 1 class (non-member Entry Derby) $80 2 classes (non-member Entry Derby) $0.00 (send in check)

Choose the fee(s) owed for your entry. Check only ONE box.

If you don't want to pay on-line, then check the $0.00 box and send in your payment to the show secretary listed above.
RELEASE: The undersigned acknowledges the inherent risk involved in riding and working around horses, which risks include bodily injury from using, riding or being in close proximity to horses among OTHER risks, and further that both horse and rider can be injured in normal use, competition & schooling.
The undersigned hereby agrees to hold harmless and indemnify the Genesee Valley Riding and Driving Club, its officers, Paul Hussey, Beth Anne, Sean and Terumi Harris (Hideaway Farm), Jeremy and Eric Grace and Doug and Judy Hart.
I furthermore release all landowners and GVRDC officers from any liability or responsibility for accident, illness or injury to undersigned or any horses owned by, leased by or in the control of undersigned or to any family member or spectator accompanying the undersigned on the grounds comprising the GVRDC grounds or any of its landowners.
In exchange for being permitted to participate in this GVRDC activity, my heirs, guardian and legal representatives and I release and agree not to make or bring any claim of any kind against the landowners mentioned above or the GVRDC officers.
My signature hereby indicates my agreement to wear protective headgear at all times as per safety guidelines set forth by the United States Eventing Association.
I have read and understand the above Release.
Type your Signature
Date:
Type Signature of Parent or Guardian (if under 18)

By doing so, your parent or guardian is certifying their agreement to your participation and the terms and conditions of the Release above.
Emergency Contact
Relationship
Phone
$0

Total

Entry for Pumpkin Derby

Entry for Pumpkin Derby

Rider Info:

Horse Info:

$0

Total

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