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AVON ZONE ODE ENTRY FORM

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					                                     2011 AVON ZONE ODE ENTRY FORM
                                  This event is part of PCAWA Junior Committee Eventing Series
                                                           Sunday, JUNE 19, 2011
                                                   ENTRIES CLOSE 1 June, 2011
                                    (NOTE: entries will be closed if classes fill prior to closing date)
                                                ONE FORM PER RIDER (Please Print Clearly)

Rider Name:                                                                                              Age (as at 1/1/2011)
Address:                                                                              Suburb                                    Postcode
Phone Number:                                            Email Address
Current Pony Club                                                                                    PCAWA No. or
                                                                                                   PCAWA Insurance No.
Pony Club Team Nomination         Yes / No      Team Name
Emergency Contact Name                                                                    Emergency Phone No.

Name of 1st Horse                                                                    Horse's Age                   Class No.          Grade

Name of 2nd Horse                                                                    Horse's Age                   Class No.          Grade
                                    ENTRY FEE PER HORSE (Avon Zone $50.00/ other PCAWA $60 .00/ Open Non PCAWA $80.00)            1   $
                                                                                                                                  2   $
                                                                                             Compulsory Ground Fee per Horse      $10 $
                                                                 Non PCAWA Insurance (unless you supply PCAWA card with entry) $10 $
                                                                                NON HELPER FEE (Sorry No self help available) $100 $
                                                                                                                           TOTAL $

      EFT Payments may be made direct to Bendigo Bank BSB 633000 A/c 118477363                Account Name : South Midlands Pony Club
      (you must send a copy of the receipt with your entry forms to be Validated) email address for entries tracy.talbot@wallisdrilling.com.au
                                  NOTE emailed entries will only be validated when payment has been received.
                           Cheque or Money Orders made out to AVON ZONE, can be posted along with Entry forms to
                                            2011 AVON ZONE ODE ENTRY FORM
                                        This event is part of PCAWA Junior Committee Eventing Series
                                                                      Sunday, JUNE 19, 2011
                                                            ENTRIES CLOSE 1 June, 2011
                                          (NOTE: entries will be closed if classes fill prior to closing date)
                                                        ONE FORM PER RIDER (Please Print Clearly)

                                             Event Organiser Avon Zone ODE, 23A Moir Place, Midvale WA 6056

                                                           COMPULSORY HELPER DETAILS
Each rider must name a helper over the age of 16yrs or pay a NO HELPER Fee. One Horse / One Helper. If more than one rider puts the same helper
you will get more than one job.

Name ___________________________________________ Age (only if under 21yrs) ________ Mobile Phone Number ____________________

Address ____________________________________________________ Suburb _________________________ Postcode __________________

                                       Each horse / rider combination must nominate a helper over the age of 16yrs

Previous Experience of Helper (please tick and indicate previous experience)

        New ______               Some Experience           _______________________________              Competent ______________________________________

Preferred Duty (please tick preferred Duty.) Every effort will be made to give you your preferred Duty, although this is not guaranteed

        Gear Checker _____               Dressage Pencillor _______                   Show Jump Pencillor _________              Cross Country Jump Judge _________

        Show Jump Arena Party _________          Time Keeper _________                Marshall __________        Ground Crew ___________ Any _________


               Signed: ________________________________________                              Name: _________________________________________
                                                   Parent / guardian must sign this entry form if the rider is under 18 years.

                           Declaration Form and relevant Disclaimer Statement must accompany entry from and entry fees
            2011 AVON ZONE ODE ENTRY FORM
         This event is part of PCAWA Junior Committee Eventing Series
                                 Sunday, JUNE 19, 2011
                         ENTRIES CLOSE 1 June, 2011
           (NOTE: entries will be closed if classes fill prior to closing date)
                      ONE FORM PER RIDER (Please Print Clearly)

Please give details if you happy for Event Announcer to use it!
i.e. how long you and your horse/pony have been competing on ODE’s
how long you have owned the horse /pony
how long you have been riding / or in Pony Club
Any other information you wish to write down about you and your horse /pony
                         2011 AVON ZONE ODE ENTRY FORM
                   This event is part of PCAWA Junior Committee Eventing Series
                                                              Sunday, JUNE 19, 2011
                                                   ENTRIES CLOSE 1 June, 2011
                      (NOTE: entries will be closed if classes fill prior to closing date)
                                             ONE FORM PER RIDER (Please Print Clearly)

                   PONY CLUB ASSOCIATION OF WESTERN AUSTRALIA INC (PCAWA)
                                                           PCAWA DISCLAIMER STATEMENT
CLUB NAME: …………………………………………………… ........................................................................

CLUB ADDRESS: ..........................................................................................................................

I acknowledge and agree as a condition of participating in any PC or PCAWA event that neither the
Club/Coach, participants, PCAWA or any subdivision thereof, officials, volunteers, medical personnel, any
persons, promoters, sponsors, advertisers, owners and lessees of premises used to conduct the EVENTS,
shall be under any liability for my death or any bodily injury, loss or damage which may be sustained or
incurred by me, as a result of participation in or being present at the event, except in regard to any rights I
may have arising under the Trade Practices Act 1974 (Cth) (or similar State legislation).

I acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury,
disability and property damage, can, and do happen.

BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS
DISCLAIMER. I ACKNOWLEDGE THAT THIS DISCLAIMER IS VALID FOR ALL AUTHORISED CLUB, ZONE AND
STATE PCAWA EVENTS THAT I ATTEND WITHIN THE TWELVE MONTH PERIOD INCLUSIVE OF AND
FOLLOWING THE DATE I HAVE SIGNED THIS FORM.

Print Name Here                                                  Sign Here                                                 Dated

………………………………………………………………………………………………………………………………………………………………

PARENT/GUARDIAN CONSENT FOR UNDER 18 YEAR OLD PARTICIPANTS

I, ………………………………………………….. being the parent/guardian of the abovenamed, ………………………………………..,
confirm that I have read the whole of this document and have taken all necessary actions to ensure I am aware of the
activity which the abovenamed, will be asked to participate in and consent to him/her participating. In doing so, I
acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury, disability and
property damage can and do happen. I agree that neither the club/coach, participants, PCAWA or any subdivision
thereof, officials, volunteers, medical personnel, any persons, promoters, sponsors, advertisers, owners and lessees of
premises used to conduct the EVENT(S) shall be under any liability whatsoever for the death or any bodily injury, loss
or damage which may be suffered or incurred by the abovenamed or by me in or being present at any PC or PCAWA
EVENTS except for any rights the abovenamed or I may have arising under the Trade Practices Act 1974 (Cth) (or
similar State legislation).

BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS DISCLAIMER. I
ACKNOWLEDGE THAT THIS DISCLAIMER IS VALID FOR ALL AUTHORISED CLUB, ZONE AND STATE PCAWA EVENTS THAT I
AND MY DEPENDANT ABOVE NAMED ATTEND WITHIN THE TWELVE MONTH PERIOD INCLUSIVE OF AND FOLLOWING
THE DATE I HAVE SIGNED THIS FORM.

........................................................                                     ..........................................................
NAME (BLOCK LETTERS)                                                                         SIGNED

                                           DATED THIS ………………….. DAY OF …………………………… 2011

				
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