Rider’s Name _____________________________________________Entry Number: __________
Birth Date ___________ Age Group (X): __Leadline __Walk Trot __10 & Under __11-13 __14-17
Horses Name ______________________________Coggin's Accession#&Date________________
Dead Broke Youth Show
August 22, 2015 9:00 a.m. Games
August 23, 2015 9:00 a.m. Pleasure
Registration & Liability Release Form
** 1 Form per Horse and Rider Combination**
I hereby absolve and release the Dead Broke Saddle Club, and all the persons and parties connected with the horse
show, including all and any damages to my horse, equipment or attendance. I hereby agree to assume personal
responsibility for any damage caused by my horse or the members of my family, or employees in and during the horse
show. Additionally, I herby agree that if I shall be injured at any point in the show, I will not seek injury damages from
the saddle club or individuals involved with the show, but will look to my own personal health insurance.
Parent Name: ____________________________________ Date: ___________________
Street
Cell # during Show:
City
State
Zip
Parent Signature: _________________________________________________________
DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY
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Egg & Spoon 10 & Under
Egg & Spoon 11-13
Egg & Spoon 14-17
Pole Weaving 14-17
Pole Weaving 11-13
Pole Weaving 10 & Under
Key Race 14-17
Key Race 11-13
Key Race 10 & Under
Jumping Figure 8- 14-17
Jumping Figure 8- 11-13
Jumping Figure 8- 10 & Under
Barrels 14-17
Barrels 11-13
Barrels 10 & Under
**Leadline Barrels 6 & Under
One-Barrel Pennant 14-17
One-Barrel Pennant 11-13
One-Barrel Pennant 10 & Under
Speed Dash 14-17
Speed Dash 11-13
Speed Dash 13 & Under
*Rescue Race
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Showmanship 10 & Under
Showmanship 11-13
Showmanship 14-17
**Showmanship Walk-Trot
Bareback 10 & Under
Bareback 11-13
Bareback 14-17
**Bareback Walk-Trot
*Tandem Bareback
English Pleasure 10 & Under
English Pleasure 11-13
English Pleasure 14-17
**English Pleasure Walk-Trot
English Equitation 10 & Under
English Equitation 11-13
English Equitation 14-17
**English Equitation Walk-Trot
**Leadline 6 & Under
Western Pleasure 10 & Under
Western Pleasure 11-13
Western Pleasure 14-17
**Western Pleasure Walk-Trot
Western Horsemanship 10 & Under
Western Horsemanship 11-13
Western Horsemanship 14-17
**Western Horsemanship Walk-Trot
*Egg and Spoon All Ages
**Class does NOT Qualify for Champ Show & State Fair. Not Eligible to ride in loping/canter classes.
Item
Classes
Qty
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*Double Classes 22 & 31
Office charge
1
Total due
Cost
$4.00
$8.00
$5.00
Total
______
______
$5.00
$_________
Office crew initials ________
Cash or Check