Pepperell Horse Owners Association

Versatility Challenge Series

at Ten Broeck Farm

1 Old Farm Lane (formerly 49 Prescott Street)

Pepperell, MA 01463

Registration opens at 10:30 a.m. ● Course walk with Pinky at 11:45 a.m. ● Event starts promptly at noon.

There is ample trailer parking and warm-up space.

2012 Indoor Versatility Challenge

Registration Form

Name of Participant: / Age:
Address: / Cell:
City: / State & Zip Code
Email: / Riding Experience
Emergency Contact Information:
Name: ______
Tel. # ______
Date: / Parent Signature required if Rider/Participant is under 18 years of age
Print: ______
Signature: ______
Name of Horse: / Age:
Breed: / Coggins Number:
FEES: $25 first run; $10 each 2nd and 3rd
$5 off first run- Check one if entrant qualifies as
□ PHOA Member □ 4-H member / Circle Date of Event
April 21 May 19 June 16 July 14
September 22 November 17 December 8

ENTRY:

One Run $25 $ ______

Less $5 discount if applicable ______

Second run $10 ______

Third run $10 ______

TOTAL ______

For more information and/or to register please contact:

Kathy Mercurio 978-314-2260 or E-mail: also www.tenbroeckfarm.net

The Versatility challenge are based on first come, first serve basis.

Bring a copy of your negative coggins on the day of the challenge. NO DOGS PLEASE.

LIABILITY RELEASE

Safety Considerations:

It is strongly suggested that all riders wear approved helmets. All participants under the age of 18 must

wear an approved ASTM/SEI helmet.

Under both MA and NH law, a participant in equine activities assumes the risk of any injury, harm, damage or death and any legal responsibility that may occur to participant from the inherent risks associated with equine activities. In consideration of being allowed to participate in any way in PHOA activities and events, I, the undersigned, and also including persons associated with me who may not be entered in the event, (1) Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death and severe social and economic losses which might result from their own actions, inaction or other risks not known to me or us or reasonably foreseeable at this time and also from the actions and/or inactions of others (2) Assume all the foregoing risks and accepts personal responsibility for the damages following such injury, permanent disability or death (3) Release, waive, discharge and covenants not to sue PHOA, it's officers, directors or members, and other owners and leasee of premises used to conduct the event, all of which are hereinafter referred to as "releases"; from demands, losses or damages on account of injury, including death or damage to property caused or alleged to be caused in whole or in part by negligence of the releases or otherwise and (4) Have read and signed the above Waiver and Release voluntarily and understand that I have given up substantial rights. I understand that trail riding can involve being in remote areas for extended periods of time, far from communications, transportation and medical facilities; and that these areas may have many natural hazards which ride management cannot anticipate, identify, modify, or eliminate; that horses can be excitable, difficult to control, and unpredictable; and that accidents can happen to anyone, at any time.

Signature: ______Date: ______

Relation to Entrant: ______

Photo Release

Photographs, videos, and/or audio clips may be taken of participants and spectators at activities held at Ten Broeck Farm. Ten Broeck Farm, and its representatives, request the right to use all photos, videos, and/or audio clips taken of youth, adults, animals, and activities. These may be used for local newspapers, promotional brochures and email marketing, promotional purpose on web sites, and to showcase equestrian programs.

By signing this form, I consent to allow Ten Broeck Farm, PHOA and its approved representatives, to use photos, videos, and/or audio clips that they have of me participating in events at Ten Broeck Farm with or without my name and for any lawful purpose, including for example such purposes as publicity and advertising. Additionally, I waive any right to royalties or other compensation arising or related to the use of these materials.

Signature: ______Date: ______