Fix-a-Test with Cheryl Ash
This form is to be used to register to "Ride" in the Fix-a-Test with Cheryl Ash
June 29, 2019
Stemmler Stein Equine
510 Orchard Lane
Date of Birth
State / Province / Region
Postal / Zip Code
Test you are going to ride
Test of Choice- Enter name of test on next field
Prix St George
If you chose Test of Choice, Enter which test of choice test you wish to ride below
NOTE: If you don't have a current Negative Coggins Test (within 12 months) and proof of a current EHV-1 vaccination (within past 6 months), on file with the LVDA you must bring a copy with you and present it at the Registration table, or you won't be able to ride.
YES, I have a current Negative Coggins & EHV-1 Vaccination on file with LVDA
Not on file yet, I will bring my current Negative Coggins & EHV-1 Vaccination and present them to the registration table
I agree to pay the Entry Fee that applies to me below.
LVDA Youth Member Entry Fee - $35
LVDA Adult Member Entry Fee- $45
Non-Member Entry Fee- $55
RELEASE, INDEMNIFY AND HOLD HARMLESS AGREEMENT
WARNING: YOU ASSUME THE RISK OF EQUINE ACTIVITIES PURSUANT TO PENNSYLVANIA LAW - PLEASE READ THE STATEMENT BELOW CAREFULLY
In consideration for my participation in any or all of the LVDA sanctioned events during the 2018 Show Season, I agree to the following: I am fully aware and acknowledge that horse sports and competing in any of these competitions/events, involve inherent dangerous risks of accident, loss, and serious bodily injury including broken bones, head injuries, trauma, pain, and suffering or death ("Harm"). I hereby agree to release, indemnify and hold harmless the LVDA, its clinicians, officers, show managers, agents, officials, volunteers, from and against any and all loss, liability or damage arising from, or because of, or in connection with, participation in this competition or related activities and/or participation in any future LVDA sponsored competitions or events during the 2018 Show Season. If I am a parent or quardian of a junior exhibitor, I consent to the child's participation and agree to all of the above provisions and agree to assume all of the obligations of this release on the child's behalf.
Acknowledgement and Agreement of the above Release, Indemnify & Hold Harmless Agreement statement
I certify that I have fully read, understand and agree to the above Release, Indemnify and Hold Harmless Agreement Statement and hereby authorize this as my signed Release Agreement.
Signed Release Form on File with LVDA
Yes, I attended previous event and have signed release on file
No, I do not have signed release on file, this is my first event this year with LVDA
Terms and Conditions
Yes, I agree to the Terms & Conditions listed below
I understand that upon clicking the Submit button I am obligated to submit payment via the payment method chosen in the payment options section below.
I also understand that I am required to bring a current copy of a Negative Coggins Test and EHV-1 Vaccination to the clinic or I will not be able to ride in the clinic.
Please choose the Payment Option you prefer to use below:
Pay Now (Use Credit or Debit Card)
After clicking the submit button (only click once) wait several seconds for the payment screen to appear (be patient it will appear).
In the payment screen you have two options:
1. Use your PayPal account by loggin into your PayPal account(this is the choice at the top)
2. Click on the button at lower portion of screen labeled "Pay with Debit/Credit Card" to use your card and enter you card information
Pay By Check
When you choose Pay by Check and hit submit the payment check out screen will still appear after a few seconds. Simply exit out of that screen without continuing any further.
Before hitting submit write down this address to send your check to:
Jen Koch, 2225 Seipstown Rd., Fogelsville, Pa