Rider’s Name _____________________________________________Entry Number: __________
Birth Date ___________ Age Group (X): _______10 & Under _______11-13 _______14-17
Horses Name ______________________________Coggin's Accession#&Date________________
Dead Broke Youth Show
August 23, 2014 9:00 a.m. Games
August 24, 2014 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
City
Cell # during Show:
State
Zip
Parent Signature: _________________________________________________________
DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY
1. Egg & Spoon 10 & Under
2. Egg & Spoon 11-13
3. Egg & Spoon 14-17
4. Pole Weaving 14-17
5. Pole Weaving 11-13
6. Pole Weaving 10 & Under
7. Key Race 14-17
8. Key Race 11-13
9. Key Race 10 & Under
10. Jumping Figure 8- 14-17
11. Jumping Figure 8- 11-13
12. Jumping Figure 8- 10 & Under
13. Barrels 14-17
14. Barrels 11-13
15. Barrels 10 & Under
16. *Leadline Barrels 6 & Under
17. One-Barrel Pennant 14-17
18. One-Barrel Pennant 11-13
19. One-Barrel Pennant 10 & Under
20. Speed Dash 14-17
21. Speed Dash 13 & Under
22. *Rescue Race
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
Showmanship 10 & Under
Showmanship 11-13
Showmanship 14-17
Bareback 10 & Under
Bareback 11-13
Bareback 14-17
*Tandem Bareback
English Pleasure 10 & Under
English Pleasure 11-13
English Pleasure 14-17
English Equitation 10 & Under
English Equitation 11-13
English Equitation 14-17
*Leadline 6 & Under
Western Pleasure 10 & Under
Western Pleasure 11-13
Western Pleasure 14-17
**Open Snaffle Bit Western Pleasure
Western Horsemanship 10 & Under
Western Horsemanship 11-13
Western Horsemanship 14-17
*Egg and Spoon All Ages
Item
Qty
Cost
Total
Classes
____
____
1
$4.00
$8.00
$5.00
______
______
$5.00
*Double Classes
Office charge
Total due
$_________
Office crew initials ________