Hack Fun Day. 4th November 2012 TROPHIES PRIZES SASHES GARLANDS. Benmuni Road, Wanneroo am start: 1.00 pm start:

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1 Hack Fun Day 4th November 2012 LEADLINE AND WALK TROT (RINGS 1-4) commencing 8.30am Benmuni Road, Wanneroo WALK TROT CANTER (RINGS 5-7) commencing 1pm 8.30 am start: RING 1 Leadline RING 2 Junior Walk Trot (under 12 years) RING 3 Youth Walk Trot (12-17 years) RING 4 Adult Walk Trot (18 years and over) 1.00 pm start: RING 5 Junior Walk Trot Canter (under 12 years) RING 6 Youth Walk Trot Canter (12-17 years) RING 7 Adult Walk Trot Canter (18 years and over) TROPHIES PRIZES SASHES GARLANDS PRE-ENTRIES CLOSE THURSDAY, 1ST NOVEMBER 2012 ENTRIES AFTER 1 ST NOVEMBER 2012 AND ENTRIES ON THE DAY WILL INCUR A $10 LATE ENTRY FEE CONDITIONS OF ENTRY 1. The organisers/committee of the WH&PC reserve the right to cancel, alter or combine any event/s they may deem necessary on the day. 2. All persons on horseback are required to wear a recognised STANDARDS APPROVED helmet and boots, as a condition of entry. 3. Rider s age will be as at the day of the event. 4. Stallions and Dogs are not permitted on the grounds. 5. The judges decisions are final. Under no circumstances is approaching the judge, judging or coaching from the side of the arena / ring permitted. Failure to abide by this rule will lead to disqualification and forfeit of entry fees. 6. The WH&PC and it s COMMITTEE, JUDGES, OFFICIALS, DO NOT accept any liability for any accident, loss, damage, illness or injury to horses, owners, riders, spectators or any other person or property whatsoever. Entry to grounds is at your own risk. 7. The club canteen will be operational. 8. This event is open to all unofficial horses/ponies/riders. We aim to have a fun day with a relaxed atmosphere. 9. Walk-Trot classes are offered to green horses/ponies and/or inexperienced riders; who are unable to canter safely or confidently in a group. 10. A horse/rider combination may only compete in walk/trot OR walk/trot/canter rings (NOT BOTH). A horse competing in walk/trot may compete in walk/trot/canter with a different rider OR a rider competing in walk/trot may then compete in walk/trot/canter on a different horse.

2 WH&PC RING 1 Leading Rein Riders any age 8.30am start (A Rider competing in this ring cannot compete in any other ring) Judge: Melissa Versteegen LEADING REIN CLASSES (Age to be as at the date of Show - Handler to be 18yrs and over) 1.a. Best Presented Leading Rein Pony/Rider/Handler Combination (plaited ponies) 1.b. Best Presented Leading Rein Pony/Rider/Handler Combination (un-plaited ponies) 2. Leading Rein rider up to and including 5yrs of age 3. Leading Rein rider 6yrs of age up to & including 7yrs of age 4. Leading Rein rider 8yrs of age up to & including 9yrs of age 5. Leading Rein rider 10yrs and over Champion Leading Rein Rider (Champion to receive sash and trophy eligible for Supreme Walk Trot) Reserve Leading Rein Rider (Reserve to receive sash) Education / Workshops Horse Massage Bioscan Laser Therapy Red Light Therapy Therapeutic Ultrasound Electrotherapy Therapeutic Products online: 6. Leading Rein Pony up to and including 11hh 7. Leading Rein Pony over 11hh up to and including 12hh 8. Leading Rein Pony over 12hh up to & including 13hh 9. Leading Rein Pony over 13hh up to & including 14hh 10. Leading Rein Horse over 14hh 11. Lightweight Leading Rein Pony up to & including 12hh 12. Mdm / Heavyweight Leading Rein Pony up to & including 12hh 13. Lightweight Leading Rein Horse/Pony over 12hh 14. Mdm / Heavyweight Leading Rein Horse/Pony over 12hh 15. Pleasure Leading Rein Pony up to & including 12hh 16. Pleasure Leading Rein Horse/Pony over 12hh Champion Leading Rein Pony/Horse (eligible for Supreme Walk Trot) (Champion to receive sash and trophy) (winners of classes 6-16) Reserve Leading Rein Pony/Horse (Reserve to receive sash) Phone: info@equesticare.com.au Equestricare is unique in regards to our educational programs and as well as offering Sports Therapy Services we also offer an IICT approved Certificate in Equine Sports Massage which is available both in an extended and condensed format, online study courses, and Equine Entrepreneur programs. Equestricare provides a variety of services for the treatment of equine injury, pain and performance issues as well as general muscle maintenance. When you book a service from Equestricare, you know you are getting the most reputable, professional and highly skilled therapists around.

3 WH&PC RING 2 - WALK TROT CLASSES Riders under 12 years 8.30am start Judge: Ashleigh Innes 1. Best Presented Pony/Galloway/Hack (plaited) 2. Best Presented Pony/Galloway/Hack (un-plaited) 3. Rider 7 years and under 4. Rider 8 and 9 years 5. Rider 10 and 11 years Champion Junior WT Rider (Champion to receive sash and trophy) (eligible for Supreme Walk Trot) Reserve Junior WT Rider (Reserve to receive sash) 6. Pony up to & including 11hh 7. Pony over 11hh and up to & including 12hh 8. Pony over 12hh and up to & including 13hh 9. Pony over 13hh and up to & including 14hh 10. Galloway or Hack over 14hh 11. Lightweight Pony Small Pony up to & including 12.2hh 12. Mdm/Heavyweight Small Pony up to & including 12.2hh 13. Lightweight Large Pony over 12.2hh up to & including 14hh 14. Mdm/Heavyweight Pony over 12.2hh up to & including 14hh 15. Lightweight Galloway or Hack over 14hh 16. Mdm / Heavyweight Galloway or Hack over 14hh 17. Pleasure Small Pony up to & including 12.2hh 18. Pleasure Large Pony over 12.2hh up to & including 14hh 19. Pleasure Galloway or Hack over 14hh Champion Small Pony 12.2hh & under (winners of classes 6, 7, 8*, 11, 12 & 17) *if winner is 12.2hh & under Reserve Small Pony 12.2hh & under (Reserve to receive sash) Buggez BugEyes see our range at or buggez.bugeyes@facebook.com Get ready for Summer and order your Buggez BugEyes fly veils NOW - Fantastic Colours - Unique design. - Extra elastic around gullet for the perfect fit - Double stitched for durability. Mini /Foal $20 Small Pony $20 Large Pony $22 Cob $22 Full $25 Warmblood/XFull $27 Champion Large Pony over 12.2hh up to & including 14hh (eligible for Supreme Walk Trot)(Champion to receive sash and trophy) (winners of classes 8*, 9, 13, 14 & 18) *if over 12.2hh up to & inc 14hh Reserve Large Pony over 12.2hh up to & including 14hh (Reserve to receive sash) Champion Galloway or Hack over 14hh (winners of classes 10, 15, 16 & 19) Reserve Galloway or Hack over 14hh (Reserve to receive sash) Lycra bibs and skinny hoods also available Order by buggezbuggeyes@gmail.com

4 WH&PC RING 3 - Walk & Trot Riders 12 yrs up to & including 17 yrs 8.30am start Judge: Janet Innes 1.a. Best Presented Pony 14hh and under (plaited) 1.b. Best Presented Pony 14hh and under (un-plaited) 2.a. Best Presented Galloway or Hack over 14hh (plaited) 2.b. Best Presented Galloway or Hack over 14hh (un-plaited) 3. Rider 12 and 13 years 4. Rider 14 and 15 years 5. Rider 16 and 17 years Champion Youth WT Rider (Champion to receive sash and trophy) (eligible for Supreme Walk Trot) NG Equine Services Equine Therapies for Optimum Performance Reserve Youth WT Rider (Reserve to receive sash) 6. Pony up to and including 12hh 7. Pony over 12hh and up to and incl 12.2hh 8. Pony over 12.2hh and up to and incl 13hh 9. Pony over 13hh and up to and incl 13.2hh 10. Pony over 13.2hh and up to and incl 14hh 11. Lightweight Small Pony up to and incl 12.2hh 12. Mdm/Heavyweight Small Pony up to and incl 12.2hh 13. Lightweight Large Pony over 12.2hh up to and incl 14hh 14. Mdm/Heavyweight Large Pony over 12.2hh up to & incl 14hh 15. Pleasure Small Pony up to and including 12.2hh 16. Pleasure Large Pony over 12.2hh up to & inc 14hh Champion Pony 14hh & under (winners of classes 6-16) Reserve Pony 14hh & under (Reserve to receive sash) 17. Galloway over 14hh up to and incl 14.2hh 18. Galloway over 14.2hh up to and incl 15hh 19. Hack over 15hh up to and incl 15.2hh 20. Hack over 15.2hh up to and incl 16hh 21. Hack over 16hh 22. Lightweight Galloway over 14hh up to and incl 15hh 23. Mdm / Heavy weight Galloway over 14hh up to and incl 15hh 24. Lightweight Hack over 15hh 25. Mdm / Heavy weight Hack over 15hh 26. Pleasure Galloway over 14hh up to and including 15hh 27. Pleasure Hack over 15hh Champion Galloway over 14hh up to and incl 15hh (winners of classes 17, 18, 22, 23 & 26) Reserve Galloway over 14hh up to and inc 15hh (Reserve to receive sash) Champion Hack over 15hh (eligible for Supreme Walk Trot) (Champion to receive sash and trophy) (winners of classes 19, 20, 21, 24, 25 & 27) Reserve Hack over 15hh (Reserve to receive sash) BENEFITS OF HORSE MASSAGE: Improve range of motion Improve stamina Improve disposition Enhance performance Enhance gait quality Improve circulation We expect a lot from our equine friends Why not include a regular Equine Massage as part of their standard health and well-being regime. Other services: Gait Analysis Stretching and Relaxation Horse Clipping Call Nadia:

5 WH&PC RING 4 Walk & Trot Ring Riders 18 years and over (Adult Ring) 8.30am start Judge: Meredith Cox 1. Best Presented Pony/Galloway/Hack (plaited) 2. Best Presented Pony/Galloway/Hack (un-plaited) 3. Rider 18, 19 and 20 years 4. Rider 21 up to and incl 30 years 5. Rider 31 years and over Champion Adult WT Rider (Champion to receive sash and trophy) (eligible for Supreme Walk Trot) Reserve Adult WT Rider (Reserve to receive sash) 6. Pony up to and incl 13hh 7. Pony over 13hh up to and incl 14hh 8. Lightweight Pony up to and incl 13hh 9. Mdm/Heavy weight Pony up to and incl 13hh 10. Lightweight Pony over 13hh up to and incl 14hh 11. Mdm/Heavy weight Pony over 13hh up to & incl 14hh 12. Pleasure Pony up to and incl 13hh 13. Pleasure Pony over 13hh up to and incl 14hh Champion Pony (eligible for Supreme Walk Trot) (Champion to receive sash and trophy)(winners of classes 6-13) Reserve Pony (Reserve to receive sash) 14. Galloway over 14hh up to and incl 14.2hh 15. Galloway over 14.2hh up to and incl 15hh 16. Hack over 15hh up to and incl 15.2hh 17. Hack over 15.2hh up to and incl 16hh 18. Hack over 16hh 19. Lightweight Galloway over 14hh up to and incl 15hh 20. Mdm / Heavyweight Galloway over 14hh up to and incl 15hh 21. Lightweight Hack over 15hh 22. Mdm / Heavyweight Hack over 15hh 23. Pleasure Galloway Hack over 14hh up to and incl 15hh 24. Pleasure Hack over 15hh part of the Midland Bullsbrook Veterinary Group We offer all standard equine veterinary health services along with enhanced diagnostic technology and expertise unique in WA. Services that are available include: Ultrasound Radiography Endoscopy Stallion Semen Collection Artificial Insemination (chilled and frozen) Embryo Transfer Equine Veterinary Dentistry Advanced Lameness Workups Soundness Evaluations Pre-purchase Examinations Castrations Routine Large Animal Medicine and Surgery Mobile crush available Valley Equine Veterinary Clinic (08) Bullsbrook Veterinary Hospital (08) bullsbrookvet@gmail.com Champion Galloway over 14hh up to and incl 15hh (winners of classes 14, 15, 19, 20, & 23) Reserve Galloway over 14hh up to and incl 15hh (Reserve to receive sash) Champion Hack over 15hh (winners of classes 16, 17, 18, 21, 22 & 24) Reserve Hack over 15hh (Reserve to receive sash) A special thanks to all the staff at Midland Bullsbrook Veterinary Group for their fantastic service and help with our ponies over the last year. Kym - Sep2012

6 WH&PC RING 5 Walk, Trot & Canter Ring Riders under 12 years 1.00pm start Judge: TBA 1. Best Presented Pony/Galloway/Hack (plaited) 2. Best Presented Pony/Galloway/Hack (un-plaited) 3. Rider 7 years and under 4. Rider 8 and 9 years 5. Rider 10 and 11 years Champion Junior WTC Rider (Champion to receive sash and trophy) (eligible Supreme Walk Trot Canter) Reserve Junior WTC Rider (Reserve to receive sash) 6. Pony up to & including 11hh 7. Pony over 11hh and up to & including 12hh 8. Pony over 12hh and up to & including 13hh 9. Pony over 13hh and up to & including 14hh 10. Galloway or Hack over 14hh 11. Lightweight Pony Small Pony up to & including 12.2hh 12. Mdm/Heavyweight Small Pony up to & including 12.2hh 13. Lightweight Large Pony over 12.2hh up to & including 14hh 14. Mdm/Heavyweight Pony over 12.2hh up to & including 14hh 15. Lightweight Galloway or Hack over 14hh 16. Mdm / Heavyweight Galloway or Hack over 14hh 17. Pleasure Small Pony up to & including 12.2hh 18. Pleasure Large Pony over 12.2hh up to & including 14hh 19. Pleasure Galloway or Hack over 14hh Champion Small Pony 12.2hh & under (winners of classes 6, 7, 8*, 11, 12 & 17) *if winner is 12.2hh & under Reserve Small Pony 12.2hh & under (Reserve to receive sash) Champion Large Pony over 12.2hh up to & including 14hh (winners of classes 8*, 9, 13, 14 & 18) *if winner is over 12.2hh up to & inc 14hh Reserve Large Pony over 12.2hh up to & including 14hh (Reserve to receive sash) Champion Galloway or Hack over 14hh (winners of classes 10, 15, 16 & 19) Reserve Galloway or Hack over 14hh (Reserve to receive sash) Equine Sports Therapy Equine Photonic Red Light Treatments Specialised Rehabilitation Agistment Service Therapeutic Products TuffRock products No. 1 Distributor in Western Australia Hoof Wraps and Chilla Wraps also available CALL US ON brokeazquarterhorses@bigpond.com website Aiming for optimum health, and for our Equine friends.

7 WH&PC RING 6 Walk, Trot & Canter Ring Riders 12 years up to and inc 17 years 1.00pm start Judge: Jayd Barton 1.a. Best Presented Pony 14hh and under (plaited) 1.b. Best Presented Pony 14hh and under (un-plaited) 2.a. Best Presented Galloway or Hack over 14hh (plaited) 2.b. Best Presented Galloway or Hack over 14hh (un-plaited) 3. Rider 12 and 13 years 4. Rider 14 and 15 years 5. Rider 16 and 17 years Champion Youth WTC Rider (Champion to receive sash and trophy) (eligible Supreme Walk Trot Canter) Reserve Youth WTC Rider (Reserve to receive sash) 6. Pony up to and incl 13hh 7. Pony over 13hh up to and incl 14hh 8. Lightweight Pony up to and incl 13hh 9. Mdm/Heavy weight Pony up to and incl 13hh 10. Lightweight Pony over 13hh up to and incl 14hh 11. Mdm/Heavy weight Pony over 13hh up to & incl 14hh 12. Pleasure Pony up to and incl 13hh 13. Pleasure Pony over 13hh up to and incl 14hh DRESSAGE EVENTING SHOWJUMPING Lessons for all levels: o Dressage o Show Jumping o X-Country Horses taken for schooling & competition Quality horses for sale Clinics Champion Pony 14hh & under (eligible for Supreme Walk Trot Canter) (Champion to receive sash and trophy) (winners of classes 6-13) Reserve Pony 14hh & under (Reserve to receive sash) 14. Galloway over 14hh up to and incl 14.2hh 15. Galloway over 14.2hh up to and incl 15hh 16. Hack over 15hh up to and incl 15.2hh 17. Hack over 15.2hh up to and incl 16hh 18. Hack over 16hh 19. Lightweight Galloway over 14hh up to and incl 15hh 20. Mdm / Heavyweight Galloway over 14hh up to and incl 15hh 21. Lightweight Hack over 15hh 22. Mdm / Heavyweight Hack over 15hh 23. Pleasure Galloway Hack over 14hh up to and incl 15hh 24. Pleasure Hack over 15hh Champion Galloway over 14hh up to and incl 15hh (winners of classes 14, 15, 19, 20 & 23) Reserve Galloway over 14hh up to and incl 15hh (Reserve to receive sash) Champion Hack over 15hh (winners of classes 16, 17, 18, 21, 22 & 24) Reserve Hack over 15hh (Reserve to receive sash) Sophie Warren Australian Representative Internationally experienced, professional Eventing and Dressage rider and coach s.warren@live.com.au

8 WH&PC RING 7 Walk, Trot & Canter Ring Riders 18 years and over (Adult Ring) 1.00pm start Judge: Rachael Box Horseplay Equestrian Fitness 1. Best Presented Pony/Galloway/Hack (plaited) 2. Best Presented Pony/Galloway/Hack (un-plaited) 3. Rider 18, 19 and 20 years 4. Rider 21 up to and incl 30 years 5. Rider 31 years and over Champion Adult WTC Rider (Champion to receive sash and trophy) (eligible Supreme Walk Trot Canter) Reserve Adult WTC Rider (Reserve to receive sash) 6. Pony up to and incl 13hh 7. Pony over 13hh and up to and incl 14hh 8. Lightweight Pony up to and incl 13hh 9. Mdm/Heavy weight Pony up to and incl 13hh 10. Lightweight Pony over 13hh up to and incl 14hh 11. Mdm/Heavy weight Pony over 13hh up to & incl 14hh 12. Pleasure Pony up to and incl 13hh 13. Pleasure Pony over 13hh up to and incl 14hh Champion Pony (eligible for Supreme Walk Trot Canter) (Champion to receive sash and trophy) (winners of classes 6-13) Reserve Pony (Reserve to receive sash) 14. Galloway over 14hh up to and incl 14.2hh 15. Galloway over 14.2hh up to and incl 15hh 16. Hack over 15hh up to and incl 15.2hh 17. Hack over 15.2hh up to and incl 16hh 18. Hack over 16hh 19. Lightweight Galloway over 14hh up to and incl 15hh 20. Mdm / Heavyweight Galloway over 14hh up to and incl 15hh 21. Lightweight Hack over 15hh 22. Mdm / Heavyweight Hack over 15hh 23. Pleasure Galloway Hack over 14hh up to and incl 15hh 24. Pleasure Hack over 15hh Champion Galloway over 14hh up to and incl 15hh (winners of classes 14, 15, 19, 20, & 23) Reserve Galloway over 14hh up to and incl 15hh (Reserve to receive sash) Champion Hack over 15hh (eligible for Supreme Walk Trot Canter) (Champion to receive sash and trophy) (winners of classes 16, 17, 18, 21, 22, & 24) Reserve Hack over 15hh (Reserve to receive sash) Fitness for the Rider Specialised program for the individual Improve your: Balance Flexibility Core strength Stamina Cardiovascular fitness Coordination Prices: 1 on 1 50 mins: $50 1 on 1 30 mins: $30 Paired 30 mins: $25 ea Fortnightly Program: $20 Also Available: Equissage Treatments for your horse Contact for appointment now: Ashlee Thomson Tel: Mobile:

9 Wanneroo Hack Fun Day 4 November 2012 ENTRY FORM Date: Armband B/Plate: Please fill out one form per horse per ring RIDER AGE OF RIDER ADDRESS PHONE: MOBILE: HORSES NAME HORSE HH HEIGHT Please circle which ring you will be competing in: (only 1 ring per horse/rider combination) 1. Leadline 2. Walk Trot (under 12 yrs) 3. Walk Trot (12-17 yrs) 4. Walk Trot (18 yrs & over) 5. Walk Trot Canter (under 12 yrs) 6. Walk Trot Canter (12-17 yrs) 7. Walk Trot Canter (over 18 yrs) WHPC Member $35.00 Wanneroo Adult Equestrian Club Members $45.00 EA & PCAWA (Member No: ) $45.00 Non Members $55.00 Armband Number Or Breastplate Number $ 5.00 (refundable on return) no charge Second Horse, same Rider (Same Ring) $20.00 Late Entry Fee: $10.00 (if received after 1 st November 2012) PRE ENTRIES TO BE SENT TO : Wanneroo Horse & Pony Club Inc 1 Zeppelin Way, Tapping WA 6065 Fax: kymw@bigpond.net.au TOTAL: DISCLAIMER STATEMENT MUST BE SIGNED Payment Methods: CHEQUE / MONEY ORDER DIRECT BANK DEPOSIT NAME: WANNEROO HORSE AND PONY CLUB BSB: , ACCOUNT: , REF: NAME AND HACK DAY CASH

10 Member Dangerous Activity Acknowledgement Full Name of participant (and of guardian if under 18 years) Address... State..Post Code...Date of Birth... Name of Club/Organisation...Wanneroo Horse & Pony Club Inc... Membership No.... In consideration for being permitted to participate in any way in horse sport activities, I, the undersigned, understand, acknowledge and accept that: Horse sports are a dangerous activity and horses can act in a sudden and unpredictable (changeable) way, especially if frightened or hurt. There is a significant risk that serious INJURY or DEATH may result from horse sport activities. I understand and acknowledge the dangers associated with the consumption of alcohol or any mind altering drugs and agree not to drink alcohol or take drugs prohibited by law before or during any horse sports activities. I agree to follow the directions of any event organiser or official and that any misconduct or refusal by me to follow any direction of any organiser or official can result in the CANCELLATION of my participation in the activities and my immediate removal from my horse NO MATTER where that may occur. I agree to wear an approved helmet at all times whilst participating in the sport where this is required under the relevant EA and FEI rules and regulations. I have had sufficient opportunity to read this Dangerous Activity Acknowledgement and fully understand its terms and sign it freely and voluntarily. Dated: / / Signature of rider For Participants of Minority Age (Under Age 18) This is to certify that I, as a parent/guardian with legal responsibility for this participant, acknowledge, understand and accept ALL OF THE ABOVE and consent and agree to my minor child's involvement or participation in horse sport activities. Dated: / / Signature of guardian

11 PONY CLUB ASSOCIATION OF WESTERN AUSTRALIA INC (PCAWA) DISCLAIMER STATEMENT PCAWA MEMBERS CLUB NAME: WANNEROO PONY CLUB... CLUB ADDRESS:...BENMUNI DRIVE, WANNEROO... EVENT: FUN HACK DAY 4 NOV (hereafter referred to as EVENT(S) ) I acknowledge and agree as a condition of participating that neither the Club/Coach, participants, PCAWA or any subdivision thereof, officials, volunteers, medical personnel, any persons, promoters, sponsors, advertisers, owners and lessees of premises used to conduct the EVENT(S), shall be under any liability for my death or any bodily injury, loss or damage which may be sustained or incurred by me, as a result of participation in or being present at the event, except in regard to any rights I may have arising under the Trade Practices Act 1974 (Cth) (or similar State legislation). I acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury, disability and property damage, can, and do happen. BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS DISCLAIMER. Print Name Here Sign Here Dated PARENT/GUARDIAN CONSENT FOR UNDER 18 YEAR OLD PARTICIPANTS I,.. being the parent/guardian of the abovenamed,.., confirm that I have read the whole of this document and have taken all necessary actions to ensure I am aware of the activity which the abovenamed, will be asked to participate in and consent to him/her participating. In doing so, I acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury, disability and property damage can and do happen. I agree that neither the club/coach, participants, PCAWA or any subdivision thereof, officials, volunteers, medical personnel, any persons, promoters, sponsors, advertisers, owners and lessees of premises used to conduct the EVENT(S) shall be under any liability whatsoever for the death or any bodily injury, loss or damage which may be suffered or incurred by the abovenamed or by me in or being present at the EVENT(S) except for any rights the abovenamed or I may have arising under the Trade Practices Act 1974 (Cth) (or similar State legislation). BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS DISCLAIMER NAME (BLOCK LETTERS) SIGNED DATED THIS.. DAY OF 2