5-State Breeders Barrel Futurity Entry Form

13th A N N U A L

September 10th-12th, 2010
Rapid City, South Dakota

Open Pole Bending Futurity

$250 added and awards

Friday September 10th, 2010 - 5:00pm

$60 entry fee - one round - must be paid by August 1st

late entries taken the day of until 3pm with $20 late fee

E N T R Y F O R M

One Horse Per Entry Blank, Please Print

Name of Horse Registration No.

Month & Year Foaled Sex Color

Sire's Name Dam's Name

***Feel Free To Make Additional Copies of This Entry Form***

I (we) hereby make application to enter the above named horse in the 5-STATE BREEDERS POLE BENDING FUTURITY. The Futurity is subject to the rules (CLICK HERE) on the attached sheets, all of which I (we) have read and agree to the provisions contained therein as a part of this Contract. I (we) agree that ALL 5-State Breeders Barrel Futurity decisions are to be FINAL. I (we) hereby release the above 5-State Breeders Barrel Futurity, LI Productions, futurity co-sponsors, and the Central States Fairgrounds from any claim or loss to myself, rider, employee, horses and/or equipment.

Check to be paid to: Owner ________________ Rider______________________ SSN____________________________________

OWNER date_______________

RIDER date_______________

Owner's name

Rider's Name and email

Address

City, State & Zip

Phone:

Signature - Parent if Minor

Please print, fill out and mail entry blank's with attached photocopy (back and front) of registration papers with appropriate fees to:
5-State Breeders Barrel Futurity, Lana Ireland, 22650 151st Ave., Box Elder, SD 57719, 605-431-9480.

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