CCOBRA OPEN 4D

DATE__________ ONE FORM PER HORSE PLEASE

NAME ___________________________________ OPEN FEES: $__45.00__

ADDRESS______________________________________ NON-MEMBER FEE ($5.00)

CITY, ZIP_______________________________________ ARENA FEE $__10.00__

SIDE POT (12.00)

HORSE _______________________________________ TIME ONLY (3.00@) $3 x ___=$_________

MEMBER (CIRCLE ONE) YES NO OTHER CREDITS OR DEBTS __________

YEARLY MEMBERSHIP FEE $25.00

HORSE NOMINATION FEE $25.00 TOTAL FEES OWED $_________

UPON ENTERING THIS BARREL RACE I ASSUME FULL RESPONSIBILTIY FOR MYSELF, MY ANIMALS AND ANY PERSON CONNECTED WITH ME DURING MY TIME AT THE CCOBRA EVENT. I ALSO RELEASE AND HOLD HARMLESS THE ARENA OWNER/OPERATORS AND ANY PERSON CONNECTED WITH THE PRODUCTION OF THIS EVENT FROM LOSS, DAMAGE, INJURY OR DEATH.

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SIGNATURE (IF SIGNING FOR YOUTH SO STATE.)