This entry form must be sent to 4-H Trail Ride c/o Tracey Dedicatoria, P.O. Box 114., Assawoman, VA 23302
NO FAX ENTRIES ******* Deadline : March 5, 2007 ******* Limit 24 participants *******First come basis
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Date
(Official use only)
4-H MEMBER ENTRY FORM
Youth 9 to 18 years of age – No clover aged youth may compete
2007 Furnace Town 20 mile 4-H Competitive Trail Ride ("The Pocomoke Pony Run")
Name________________________________________________________________________________
Address______________________________________________________________________________
Town_____________________________________________ State_________ Zip__________________
County____________________________________________ Phone_____________________________
Age__________
Name of Horse/Pony/Mule_____________________Color_________________
Age of Horse/Pony/Mule_______ Breed or Ancestry of Horse/Pony/Mule_________________________
Mare or Gelding (circle one) STALLIONS ARE NOT PERMITTED – NO DOGS ALLOWED
PLEASE ATTACH COPY OF CURRENT (WITHIN 12 MONTHS) NEGATIVE
COGGINS/EIA TEST RESULTS AND HEALTH CERTIFICATE (WITHIN 30 DAYS OF
COMPETITION DATE) OF THE HORSE/PONY/MULE TO BE USED FOR THIS ACTIVITY
Check One: Division Entered: (check one)
Based on condition/soundness & tail ability/manners – See sample score card 3 placings
Pony Division A(Jr.) ____
Pony Division B(Sr.) ____
Horse Division C(Jr.) ____
Horse Division D(Sr.)____
Green ( equines under 7 years of age) Division E ____
Senior (equines over 16 years of age) Division F ____
I WANT TO BE JUDGED FOR THE HORSEMANSHIP AWARD – 3 PLACINGS EACH DIVISION
(presentation in-hand over a natural obstacle/tack: cleanliness, proper fit, adjustment/grooming: brushing,
dirt, sweat marks, external parasites/hooves and shoeing if applicable/trailer area: hay net height, quick
release knot, tack & gear storage. YES_____ NO____ (check one)
I certify that the above named horse is my current year trail riding project horse and that I have owned or
leased my project since January 1 of the current year. I will arrive at the Furnace Town/Pocomoke State
Forest at 7:30 a.m. for a pre-vet inspection on Saturday, March 17, (rain date Sunday March 18) 2007.
Signature of 4-H Member___________________________________ Date________________________
As this 4-H member's project leader, I certify that all the above is true to the best of my knowledge and
that this member is in good standing and is a bona fide 4-H Horse and Pony member in
_________________________County.
Signature of 4-H Horse and Pony Leader____________________________________________________
Signature of County 4-H Agent___________________________________________________________
There are no entry fees however, we are asking for donations to off set costs for the veterinarian, facilities
use and awards (make check payable to: Accomack County 4-H/ESTB) and mail your 4-H entry form
with a completed parent-release form, Virginia Equine Waiver & 4-H Health History Form (copies
acceptable) to: Tracey Dedicatoria, P.O. Box 114, Assawoman, VA 23302.
ENTRY DEADLINE IS March 5, 2007 (NO FAX ENTRIES)
Parent Release Form
Furnace Town 4-H Competitive Trail Ride
I consent to permit my child to compete in and attend the Furnace Town 4-H Competitive Trail Ride, to
be held in Pocomoke State Forest (Worcester County, MD) on March 17 (rain date March 18), 2007.
The undersigned ________________________________(parent or guardian) expressly acknowledges
and voluntarily assumes all risks and dangers associated with or arising from the activity of horseback
riding which is or may be involved in the 4-H Trail Riding Project. I further acknowledge that although
appropriate care will be taken to ensure safety, the potential for injury nevertheless is inherent in the
activity of horseback riding. Intending to be legally bound, I, the undersigned, for myself, my heirs and
assigns, executors and administrators, hereby discharge and forever release Virginia Tech. University, its
trustees, officers, agents, employees, including without limitation all individuals associated with the 4-H
Trail Riding Project, from any and all claims, causes of action and liability for personal injury or property
damage that I, my son, my daughter, or my ward may sustain while participating in the 4-H Trail Riding
Project.
In case of accident or serious illness, the Trail Ride Committee has authorization to secure such
medical attention for: _____________________________________________as deemed necessary.
(Name of 4-H Member)
This authorization applies whether the charges for medical treatment are covered by 4-H insurance or by
myself.
This also certifies that my child is physically able to participate in all the activities of the above event and
will be supervised at the event by me or my assigned representative.
Please list any physical or medical conditions of this 4-H member listed above that the ride committee
should be aware of . If receiving medication what is it and the
dosage?______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I also certify that the above named 4-H member has properly conditioned the horse/mule or pony
he/she is using on this 20 – 25 mile ride. I certify that the above mentioned 4-H member will wear
protective headgear that is properly fitted and in good safe condition at all times when riding.
_________________________________________________________________________________
(Signature of Parent or Authorized Guardian)
__________________________________________________________________________
__________________________________________________________________________
(Address)
Telephone Number:__________________________________________________________
EMERGENCY CONTACT NAME & NUMBER:__________________________________
__________________________________________________________________________
2007 Furnace Town 20 mile 4-H Competitive Trail Ride
“The Pocomoke Pony Run”
Relatively flat terrain with wooded trails and dirt forest roads, some low lying areas may have
large puddles
Saturday March 17 (Rain date Sunday March 18)
Check in/vet in 7:30 a.m./ Limited to 24 participants on a first come basis
Ride Rules & Regulations:
* All participants must be a member of an Equine 4-H program in one of the following counties
and be between 9 and 18 years of age. Cloverbuds may not compete.
Worcester (MD)
Wicomico (MD)
Accomack (VA)
Northampton (VA)
Somerset (MD)
* All equines are welcome and encouraged to participate this includes mules, ponies and horses.
* All riders must wear an approved equestrian helmet and have foot wear with an adequate heel.
* All equines must be at least 5 years of age and have a current health certificate from a licensed
veterinarian (within 30 days of competition date).
* Each participant must complete a VIRGINA Equine Waiver Form, Parent Release Form, 4H Member Entry Form and Health History Form. Health History Forms on file at the
extension office may be reproduced if current.
* There are no entry fees however, donations to offset our costs are appreciated.
* Equines must pass a pre-ride vet inspection for lameness/ and other health issues that may
affect the ability for the animal to compete.
* At the mid point check station the in time will be recorded and in 10 minutes the rider and
mount will be called for a P&R check.
* Any equines failing to reach adequate heart rate recovery time or showing signs of lameness or
severe fatigue at the 10 mile vet check in will not be allowed to continue and subsequently be
disqualified. (Veterinarian’s discretion)
* Any medication done by a veterinary judge will be at the rider’s expense.
* Participants will start in pairs at 30 second intervals.
* The trail will be marked clearly with orange surveyors flagging.
* Trail courtesy and appropriate conduct reflecting 4-H values is expected of all participants.
Poor sportsmanship will not be tolerated.
* Riders must remain in the saddle while moving over the course. Dismounting and resting of
horse and rider is permitted providing they do not advance forward.
* Riders who leave the trail intentionally or otherwise must return to that same point to continue
the ride.
* Saddles are required. However any combination of saddle and bridle is acceptable as long as it
is in good repair and not cruel to the animal. i.e. English saddle, western bridle etc.
* Pain medications and anti-inflammatories such as Bute are strictly prohibited.
* No smoking or littering allowed on the trail. Removal of trail markers is also prohibited.
Violation of these rules will result in disqualification.
* All participants that complete the 20 mile ride in adequate condition within the allotted time
frame will receive a completion award.
* Ride pace 4.5 to 6.5 mph, maximum ride time 4 hrs 24 min./minimum ride time 3 hrs 20 min.
* Veterinarian judge TBA.
* All documents and donations should be mailed to 4-H Trail Ride c/o Tracey Dedicatoria, P.O.
Box 114 Assawoman, VA 23302. Post marked by March 5, 2007. No faxed entries will be
accepted. Checks should be made payable to Accomack County 4-H/ESTB.