YOUTH DIVISION 10 - 15 YEARS

DATE _____________ ONE FORM PER HORSE PLEASE

NAME_________________________________________________________YOUTH $ 25.00______

ADDRESS_______________________________________________Non-Member Fee ($5)____________

CITY, ZIP______________________________________________________ARENEA FEE $10.00______

HORSE ___________________________________________________ONE TIME ONLY __FREE_______

YOUTH MEMBER (CIRCLE ONE) TIME ONLY (3.00@)_ $3 x ______ = _______________

YES NO OTHER CREDITS OR DEBTS______________

YEARLY MEMBERSHIP FEE $25.00

TOTAL FEES OWED $_____________

UPON ENTERING THIS BARREL RACE I ASSUME FULL RESPONSIBILITY 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.

SIGNATURE (IF SIGNING FOR YOUTH SO STATE.)