Games, Flat & Musical Ride Teams State Championships Entry Form

2015 PONY CLUB ASSOCIATION OF VICTORIA INC A13413S

GAMES, FLAT & MUSICAL RIDE TEAMS STATE CHAMPIONSHIPS ENTRY FORM

OFFICIAL ENTRY FORM FOR KAY IRVING MEMORIAL GAMES TEAMS from ______ZONE

$45.00 PER RIDER ...... Riders X $45.00 = ......

CLUB NAME: / **Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
1
CLUB COLOUR: / 2
3
TEAM MANAGER: / 4
5
TEAM MANAGER MOBILE NO:
EMAIL: / 6
7
CLUB NAME: / **Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
1
CLUB COLOUR: / 2
3
TEAM MANAGER: / 4
5
TEAM MANAGER MOBILE NO:
EMAIL: / 6
7
CLUB NAME: / **Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
1
CLUB COLOUR: / 2
3
TEAM MANAGER: / 4
5
TEAM MANAGER MOBILE NO:
EMAIL: / 6
7

**Please note that yards will only be allocated to horses for one night, except for horses competing on both days. Flat Teams horses wishing to stay on the Saturday night will only be allocated a yard, after all Games horses requesting a yard, have been allocated.

We the undersigned verify that all the above named combinations are eligible and have qualified as per the rules of the competition to compete in the PCAV 2015 Games, Flat & Musical Ride Teams State Championships. ENTRIES CLOSE FRIDAY 15TH MAY, 2015

Signed: Signed:

Zone Representative Zone Secretary

Preferred method payment – Direct Deposit - BSB: 013355, Account No.: 260054734, Account Name: The Pony club Association of Victoria Inc.

Entries to: State Event Secretary, Mrs. Judy Beasley, 490 Hamilton Highway, STONEHAVEN, Vic. 3218 Mob. 0407 552 364

OFFICIAL ENTRY FORM FOR TEAMS OF FOUR RIDE from ______ZONE

$45.00 PER RIDER: ...... Riders X $45.00 = ......

**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER: / 3
TEAM MANAGER MOBILE NO:
EMAIL: / 4
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER: / 3
TEAM MANAGER MOBILE NO:
EMAIL: / 4
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER: / 3
TEAM MANAGER MOBILE NO:
EMAIL: / 4

We the undersigned verify that all the above named combinations are eligible and have qualified as per the rules of the competition to compete in the PCAV 2015 Games, Flat & Musical Teams Ride State Championships. ENTRIES CLOSE FRIDAY 15TH May, 2015.

Signed: Signed:

Zone Representative Zone Secretary

Preferred method payment – Direct Deposit - BSB: 013355, Account No.: 260054734, Account Name: The Pony club Association of Victoria Inc.

Send Entries to: State Event Secretary, Mrs. Judy Beasley, 490 Hamilton Highway, STONEHAVEN, Vic. 3218 Mob. 0407 552 364

OFFICIAL ENTRY FORM FOR IAN WARDELL MUSICAL RIDE TEAMS from ______ZONE

$45.00 PER RIDER: ...... Riders X $45.00 = ......

**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME:
CLUB COLOUR: / 1
CLUB THEME: / 2
TEAM MANAGER: / 3
TEAM MANAGER MOBILE NO:
EMAIL: / 4
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME:
CLUB COLOUR: / 1
CLUB THEME: / 2
TEAM MANAGER: / 3
TEAM MANAGER MOBILE NO:
EMAIL: / 4
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME:
CLUB COLOUR: / 1
CLUB THEME: / 2
TEAM MANAGER: / 3
TEAM MANAGER PHONE NO:
EMAIL: / 4

We the undersigned verify that all the above named combinations are eligible and have qualified as per the rules of the competition to compete in the PCAV 2014 Games, Flat & Musical Ride State Championships. ENTRIES CLOSE FRIDAY 15TH MAY, 2015

Signed: Signed:

Zone Representative Zone Secretary

Preferred method payment – Direct Deposit - BSB: 013355, Account No.: 260054734, Account Name: The Pony club Association of Victoria Inc.

Send Entries to: State Event Secretary, Mrs. Judy Beasley, 490 Hamilton Highway, STONEHAVEN, Vic. 3218 Mob. 0407 552 364

OFFICIAL ENTRY FORM FOR PAIRS TEAM RIDE from ______ZONE

$45.00 PER RIDER: ...... Riders X $45.00 = ......

**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER:
TEAM MANAGER MOBILE NO:
EMAIL:
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER:
TEAM MANAGER MOBILE NO:
EMAIL:
**Yard
Fri/Sat / No. / Rider Name: / Age / Horse:
CLUB NAME: / 1
CLUB COLOUR: / 2
TEAM MANAGER:
TEAM MANAGER MOBILE NO:
EMAIL:

We the undersigned verify that all the above named combinations are eligible and have qualified as per the rules of the competition to compete in the PCAV 2015 Games, Flat & Musical Ride State Championships. ENTRIES CLOSE FRIDAY 15TH MAY, 2015

Signed: Signed:

Zone Representative Zone Secretary

Preferred method payment – Direct Deposit - BSB: 013355, Account No.: 260054734, Account Name: The Pony club Association of Victoria

Send Entries to: State Event Secretary, Mrs. Judy Beasley, 490 Hamilton Highway, STONEHAVEN, Vic. 3218 Mob. 0407 552 364

COMPULSORY MEDICAL AND HORSE/VETERINARY AUTHORITY

Must accompany entry form: Post to the State Event Secretary by Friday 15th May 2015

MEDICAL

Address: Post Code:______

Ambulance Cover? YES / NO (Please Circle) No. ______

Please complete the following section if rider is Under 18 years. Organisers suggest that all competitors complete this section) Accompanying Parent/Guardian/Responsible Adult:

Adult: ______

Address: ______

Telephone No: Mobile: ______

I being the parent/guardian/responsible adult named above or, if no person is named being the competitor aged 18 years or over, give permission for the competitor named above to receive FIRST AID and/or MEDICAL TREATMENT, and being transferred to hospital by ambulance should the need arise during the conduct of the 2015 PCAV Games, Flat & Musical Ride Teams State Championships held at Bacchus Marsh Recreation Centre on the 20th & 21st June 2015.

I give the President of the Pony Club Association of Victoria Inc. (PCAV), or his/her appointed deputy, my consent to authorize such transfer and to make such emergency medical arrangements as may be deemed necessary by a qualified medical practitioner on my behalf. Before taking this action, the President of PCAV, or the appointed deputy, must be satisfied that every possible practical effort has been made to contact the accompanying parent/guardian/responsible adult named above. I give authority in the full knowledge that I will be required to pay costs incurred if insurance held by the PCAV does not cover the ambulance transfer, medical treatment or any other costs involved.

Signature: Date: ______

HORSE / VETERINARY

Registered name of horse and / or name as officially entered ______

Address of property from which the horse will be moved to the event ______

Address of property to where the horse will move after the event

______

I being the owner/lessee of the above named horse, hereby consent to the Official Veterinary Officer providing such treatment as is deemed necessary to this horse in the case of an accident at the 2015 PCAV Games, Flat & Musical Ride Teams State Championships held at Bacchus Marsh Equestrian Centre on the 20th & 21st June 2015. I agree to be fully responsible for all service or consultation fees charged as a result of such accident. In a case where it is deemed by the Official Veterinary Officer that on humanitarian grounds the above named horse should be destroyed because of illness, injury or accident, I hereby give the Official Veterinary Officer and the President of PCAV, or the appointed deputy, permission to act in accordance with the recommendation of the Official Veterinary Officer in this matter. Before taking this action the President of the PCAV, or the appointed deputy, must be satisfied that every possible practical effort has been made to contact the accompanying parent/guardian/responsible adult named above. I list below any special conditions or instructions as to the disposal of the horse after such action by the Official Veterinary Officer.

Health of Horse(s)

I declare that the horse named above will be in good health, eating normally and not showing signs of respiratory disease during the last 3 days leading up to this event. I give my authorisation for the Event Secretary to call for veterinary inspection of the horse/(s) named above and in my care should they be showing signs of a respiratory illness at any time during the course of the event. I agree to pay any veterinary fees incurred as a result of this veterinary examination.

______

Signature of Competitor Signature of Parent

Dated:

HORSE EVENT DECLARATION WAIVER

I understand that due to diseases such as equine influenza, the Victorian Department of Primary Industries, or other State or Commonwealth government body, may restrict or prevent the movement of horses, vehicles and personnel for a period of time (“Standstill”). I acknowledge and agree that a Standstill is a risk of competing at this event and I agree to pay all costs or expenses incurred by PCAV as a result of a Standstill.

CONDITION OF ENTRY

I hereby agree to abide by the conditions and rules as specified by the PCAV and the Organising Committee for the 2015 Games, Flat & Musical Ride Teams State Championships. Failure to comply with the conditions of entry may result in disqualifications

______

Signature of Competitor Signature of Parent

Dated: