at Trott Brook Farm
Opening Date April 24 Closing Date May 22
Entry Packet – Please include the following when you send in your entry to Jennifer Johnson:
- This entry form completed and signed (riders under 18 years need guardian to sign)
- Completed and signed "Participant Release Form for USEA Educational Activity"
- Legible copy of negative Coggins Test within 12 months
- Check for entries made to Jennifer Johnson, $275/entry for the weekend.
- Format – 1st day gymnastics prep, 2nd day cross country school. A few private lessons available on Friday afternoon June 15th for $90/45minutes
- Cancellation/Refunds –after closing date, no refund unless spot is filled from the waiting list.
- Safety –wear approved helmets, safety vests, medical cards and appropriate clothing.
- Weather – we will ride in the rain if need be, unless it is storming or otherwise dangerous.
- Stabling – No stabling on grounds. Local stabling available. Contact organizer for information.
Entry Information (Print in LAND Format):
Rider Name ____________________________ Guardian(for riders under 18) _____________________
Address ___________________________City _____________________ State_________Zip_________
Phone home (____)________________ Work (____)__________________ Cell (____)______________
Horse Name ____________ Age ____ Level we currently compete at: BN__ N__ T__ P__ I__
USEA# ____________ if not a current USEA member, add $10 per DAY to entry
E-Mail Address (schedules and updates will be on email)______________________________________
Special Scheduling information – include any special time requests, trailing arrangements, or desire to ride at a higher level than you’ve competed at and why:
______________________________________________________________________________________________________________________________________
All Participants MUST Sign the Following Release:WARNING: Each participant who engages in an Equine Activity expressly assumes the risks of engaging in and legal responsibility for injury, loss or damage to person or property resulting from the risk of equine activity. I understand that this is a high risk sport and I am participating at my own risk. I hereby release and hold harmless Trott Brook Farm, its owners and employees, attendants, spectators, organizers, and all others involved from all liability for accidents, damage, injury, or illness sustained or caused as a result of my participation in this clinic.
Release Form For USEA Educational Activities
Name of Registered Activity: USEA Eric Dierks Clinic________ Area: ___IV_____
Date(s): June 15-17, 2007 Location: TrottBrook Farm State: MN
I have applied to participate in this USEA sponsored educational activity. I agree that my participation is subject to the conditions in this release and to those set by the organizer of this activity, the regulations and requirements of the USEA, and, where applicable the U.S. Equestrian Rules for Eventing.
I agree to wear protective headgear when riding. When jumping, I agree to wear protective headgear with harness attached that meets standards currently imposed by the U.S. Equestrian Rules for Eventing. (Helmets passing or surpassing the AST/SEI standards are strongly encouraged when jumping.) I understand that the USEA strongly recommends all riders in cross-country wear body-protecting vests that meet or exceed current U. S. Equestrian rules and wearing of an approved medical armband; if the activity Organizer requires vests and /or armbands to be worn, I agree to do so.
I understand that the sport of eventing is a high risk sport, and that my participation in this educational activity may also involve participation in an "equine activity" as defined by applicable laws and is wholly at my own risk. I understand that my participation involves all inherent risks associated with the dangers and conditions which are an integral part of equine activities, including, but not limited to, the propensity of equines to behave in ways which may result in injury, harm or even death to humans or other animals around or near them; the unpredictability of equine reaction to sounds, sudden movement, smell, and unfamiliar objects; persons or other animals; hazards related to surface and subsurface conditions; collisions with other equines or objects and, the potential of a participant to act in a negligent or unskilled manner which may contribute to injury to the participant of others, including failing or inability to maintain control over the animal. By participating in this activity I agree to assume responsibility for those risks, and I release and agree to hold harmless the activity organizer, organizing committee, officials the USEA, U.S. Equestrian, their officers, agents, employee and the volunteers assisting in the conduct of the USEA educational activity and the owners of the property, including the horse(s) which I may ride.
I understand and agree that the organizer of this USEA educational activity has the right to cancel this activity,; to refuse any entry or application; to require and enforce the wearing of safety or other attire and the conduct of riders, horses, and visitors; and to prohibit, stop or control any action during the activity deemed by the organizer to be improper or unsafe.
THIS FORM MUST BE FILLED OUT COMPLETELY AND SIGNED IF YOU WISH TO PARTICIPATE IN THIS ACTIVITY.
Participant’s Name (Please Print):_____________________________________________________________________________
Address: ____________________________________________________ City: ___________________________________
State: _____________ Zip: __________________ Phone: __________________________ Fax: _____________________
Email: _____________________________________ Number of horses I will be riding during activity (if applicable):________
Level now riding (check one if applicable): ___Beginner Novice ___ Novice ___Training ___Preliminary ___Intermediate ___Advanced
- I am a USEA member and my number is #: __________________________________
- I am not a USEA member and have paid the Organizer $10.00 per day additional fee.
- Number of days attended: ______________________
- I am not a USEA member. I wish to join and enclose my membership form and dues. (non-members who complete membership application form and submit it with their dues and this form to Organizer do not pay the non-member fee for the activity).
SIGNATURE: ___________________________________________Date: _______________________(if Participant is under 18, Release must be signed by Parent or legal guardian, not by trainer or instructor).
ORGANIZER – this person: ____paid a non-member fee of $10/day ____is/or became a member of USEA
USEA / Eric Dierks Clinic
June 16-17
Directions
Directions to Trott Brook FarmTake Hy. 10 North/West to Anoka. Exit at Hwy 47 North (St. Francis Blvd). Turn right at the top of the exit. Go about 6.5 miles north to 17902 St. Francis Blvd. The driveway is on the left side of the road directly across from the intersection of County Road 27, so watch for those signs. If you get to a stop sign at County Road 22, you’ve gone too far.
Cell phone contact the day of the clinic: Jennifer Johnson 612-655-0316
Please print all forms in Landscape. Thank you!
Questions? Mail Entries to:
Jen Johnson 612-655-0316 (C) Jennifer Johnson 3444 Benjamin St NE Minneapolis, MN 55418
email: jlj@umn.edu