PONY CLUB ASSOCIATION OF VICTORIA

HORSELANDINTERZONE TEAM HORSE TRIALS 2012

INDIVIDUAL ENTRY FORM

Inc No A13413S

ENTRIES CLOSE FRIDAY 8th June, 2012 (or date set by Zone)

To your Zone Rep or Interzone Co-ordinator

YOUR CHECK-LIST:

  1. Entry Forms for either or both Grades 3 & 4 competitors.
  2. Medical & Horse Veterinary Authority Forms for every horse/rider combination - with entry to zone
  3. Pre-Order Form for Merchandise –and payment to zone
  4. Order for Catering – Requirements for non-rider Saturday Evening Dinner - and payment to zone by 8th June
  5. CHEQUES TO BE MADE PAYABLE to your zone as applicable

SATURDAY EVENING DINNER:

A meal, on the Saturday evening, 21st July, is also available for $25.00. It must be ordered and prepaid with this entry form

CAMPING:

Camping is permitted on site at no cost. Un-powered sites only. Bookings do not need to be made.

STABLING AND YARDS:

Riders who are camping overnight should bring their own yards. Tape may be used but MUST be electrified. A limited number of Day Yards are available on a first come, first served basis. There is NO stabling at the venue.

MERCHANDISE:

All clothing and capswill be in navy with green trimmings and a green logo (Interzones Horse Trials 2012) and should be pre-ordered and pre-paid with your zone entry. See the order form for prices.
INDIVIDUAL ENTRY FORM- GRADE 3 & 4 Note: some Zones have their own entry form. Please check before you use this generic one.

Name of Rider: / Date of Birth:
Address of Rider:
Town/Suburb: / Postcode:
Phone (H): / Mobile:
Email:
Club:
Horse Name: / Grade:
Team Name Suggestion:

Your Medical and Veterinary Form must be forwarded with the entry for each combination.

Declaration:
I have read the rules and conditions and agree to abide by them. In the event of a scratching, I agree to notify the Zone Representative as soon as possible so that a substitute from the reserve list can be contacted.
Rider Signature: ………………………………………………………………………………………
Signature of Rider’s parent/Guardian/Responsible Adult: ………………………………………………………………………………………………………
Competency Sign-off: Zone Representative’s Signature: ………………………………………………… ZONE….……………………...

Times will be available on PCAV website as soon as available

COMPETITON FEES

Competition Entry Fee $70(GST inc)/Combination: / $70.00
No of Sat night meals ………………………… @$25: / $
Total of merchandise ordered: / $
Total paid: (Make cheques payable to your Zone) / $

Entry closing date - Friday 8th June, 2012

COMPULSORY MEDICAL AND HORSE/VETERINARY AUTHORITY

Must accompany entry form: Post to Zone Rep or ZoneInterzones coordinator by Friday 8th June, 2012

MEDICAL

Address: Post Code:_____

Ambulance Cover? YES / NO Please Circle

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:

Ibeing 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 2012 PCAV Interzone Horse Trials Championships held at Yarrambat Pony Club on the 21st22nd July 2012.

I give the President of the Pony Club Association of Victoria Inc. (PCAV), or 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

______

Ibeing 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 2012 PCAV Interzone Horse Trials Championships held at Yarrambat Pony Club on the 21st and 22nd July 2012. 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 CompetitorSignature 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 for my horse 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 2012Interzone Horse Trials Championships. Failure to comply with the conditions of entry may result in disqualifications

Signature of Competitor Signature of Parent

Dated:

StateInterzone Teams Horse Trials Merchandising Form

Please note that ALL pre-orders MUST be in no later than Friday 8th June 2012(or the date specified by the zone). All merchandise will be available to collect at the event. If you are not attending the event, please advise on the order form who is collecting the items for you.

All cheques/money orders need to be included with your entry fee and made payable to your zone. There will be a limited amount of merchandising for sale at the event also, or orders can be taken on the day. All merchandise will feature a 2012 State Interzone Teams Horse Trials Logo embroidered in green. Polo/Hoodie tops/Caps are navy blue.

StateInterzone Teams Horse Trials Merchandising Form

To be completed and returned to your zone together with the other entry forms

no later thanFriday 8thJune 2012 (or the date specified by the zone).

Size / Garment and code
(Polo / Cap / Hoodie ) / Quantity / Item cost
eg. 8 kids / P7700 polo / 1 / 36.00

Total Cost $…………………

Name:……………………………………………………………………….

Address:……………………………………………………………………………….

Phone No:……………………………. Pony Club:………………………………….

Zone:…………………………………………………………………………

NB – THIS FORM NEEDS TO BE READ IN CONJUNCTION WITH SCHEDULE.
PLEASE INCLUDE INDIVIDUAL RIDER’S MEDICAL AND VETERINARY FORMS.