MODERN PENTATHLON QUEENSLAND INC Fence, Swim, Ride, Run, Shoot ABN

Transcription

1 NOMINATION ENTRY FORM EVENT: 2017 Modern Pentathlon QLD State Championships Brisbane, Queensland, Monday 2 October 2017 COMPETITOR DETAILS Full Name: Street Address: Postal Address: Phone (Home and Mobile): EVENT NOMINATION DETAILS (tick one) EVENT DETAILS COST TICK 1. UIPM MODERN PENTATHLON Swim, Fence, Ride, Combined event $75 2. UIPM JUNIOR PENTATHLON Swim, Fence, Combined event $50 3. UIPM TETRATHLON Swim, Fence, Combined event $50 4. PONY CLUB TETRATHLON Swim, Ride, Combined event $60 5. UIPM TRIATHLE Swim, Combined event $35 6. UIPM BIATHLE Swim, Run $20 7. Pony club Showjumping Ride (own horse) (2 rounds) $20 8. Fencing Fence $15 9. Shooting Shoot (laser pistol)(high point winner) $ Swimming Swim $ Running Run $5 NB: Insurance Levy of $20 for the day will be applicable for Non-MPQ Members NB: Pistol Levy of $5 for the day will be applicable for non-pistol owners to borrow a MPQ pistol. This ensures the maintenance and quality of equipment. Entrants in the showjumping have the opportunity to be paid $20 for each round of showjumping if their horse is nominated for and used for Event 1. Contact Cathy McCarthy for further information. MEMBERS Are you a member of Modern Pentathlon? Yes/No If so, please indicate which state... Are you a member of a Pony Club? If so, please indicate which club Yes/No.. /MAIL completed form to Roxanne Coleman at: roxanne.coleman@hotmail.com Or post to 71 Greentrees Ave, Brookfield, QLD 4069.

2 MEMBERSHIP 2017/2018 Full Name: Date of Birth: Male/Female: Street Address: Postal Address: Phone (Home and/or Mobile): MODERN PENTATHLON QUEENSLAND INC Modern Pentathlon Queensland Inc has $10 million Public and $10 million Products Liability, $1 million Professional Indemnity per claim and in the aggregate and Personal Accident Insurance. TICK MEMBER FEE CATEGORY Fees: 01/04/ /03/2018 Tick Fee Level Category Adult $150 U19 (YA, YB, YC) $100 U13 (YD, YE, YF) $50 Associate $25 Day Insurance $20 Pistol Levy $5 ENTRY FEE + *MEMBERSHIP + *PISTOL LEVY BANK DEPOSIT DETAILS BSB Account Please prepay event fees direct to bank account by 29 th of September (NB: Include your name on the deposit so as to identify your payment) Late entry Acceptance of late entries and payments of entries on the day of competition will be at the sole discretion of the MPQ Management Committee. *See terms and conditions to see if membership and/or pistol levy apply to you.

3 HEALTH INSURANCE, AMBULANCE COVER DETAILS Medicare Number: Private Medical Insurance Details Next of Kin Name & Contact Details (in case of injury) FLIGHT DETAILS Arrival Flight and Time Details Departure Flight and Time Details BILLETING ACCOMODATION Yes, I require billet accommodation for ( ) nights HEALTH INFORMATION (ie. Special Dietary Requirements, Allergies, Asthma, Medical Conditions etc) COMMITTEE CONTACT DETAILS Mark Taylor mark@taylorsix.com Cathy McCarthy equinepartnerships@bigpond.com Roxanne Coleman roxanne.coleman@hotmail.com Lauren Boyd lauren.boyd@westnet.com.au Kim Watkinson horsegal_1@hotmail.com Jamie Webb accesstax@bigpond.com

4 Terms and Condition of Entry for MPQ State Championships 2 October Members: Competitors must be paid Ordinary or Junior Member of MPQ or equivalent state body (eg. MPV, MPWA, MPNSW). All junior (U19) members of MPQ must have an adult/parent/guardian/responsible adult take a minimum of associate membership. 2. Day insurance: Applies to non-members of MPQ/equivalent state bodies. Day insurance may be used a maximum of two times/competitions by any individual, at which point 50% of which can be credited toward the cost of full membership. This does not include entry fees to events or other associated costs eg. equipment hire. 3. Pistol Levy: To facilitate the continued excellent quality of borrowed equipment, the pistol levy contributes to the maintenance cost of the MPQ borrowed pistols. 4. Riding Event: To participate in the Riding Event, Members must: a. Have a Riding Certificate (Senior, Novice & Junior Certificates available); and b. Otherwise comply with the UIPM Rules for the Riding Event as far as they are relevant and with any direction or instruction given by or on behalf of MPQ. 5. Late Entry: In order for your entry to be eligible Entry Fees must be received in MPQ s bank account by 29 th of September Acceptance of late entries on the day of competition will be at the sole discretion of the MPQ Management Committee. 6. Dangerous Activity Acknowledgement/Waiver: All Competitors (or a parent or guardian for Junior Members) must complete the attached waiver. Please bring the completed Waiver with you on 2 October Withdrawal: Must be notified in writing to event organisers by 29 th September 2017: a. No refunds will be provided for withdrawals not notified in writing. b. Entry Fees will be refunded in full to any Competitor whose withdrawal is received by COB on 29 th September 2017; and c. Entry fees in respect of Withdrawals received after 29 th September 2017 will not be refunded, except at the sole discretion of the MPQ Management Committee, which may request any further information in respect of the Withdrawal. 8. Cancellation/Amendment: MPQ reserves the right to cancel any Event, alter the order or venue, or run any Event in any way it deems fit. a. MPQ Management Committee reserves all rights to cancel the Riding Event at any time prior to 2nd October If this occurs MPQ will refund the portion of the Entry Fee for this event to all Competitors entered for that event. b. In the event the Competition is cancelled due to events outside the control of MPQ, any refunds will be made at the discretion of MPQ Management Committee and with reference to any unavoidable costs already incurred by, or on behalf of MPQ; c. No other refunds will be made in respect of any changes to the Schedule, Events or any other aspect of the Competition. 9. Transport: The organisers will assist in providing transport between the swimming venue and the Brookfield Showgrounds (remainder of events). 10. Equipment: Athletes must supply their own equipment. Some equipment may be available to borrow from organisers, but cannot be guaranteed.

5 Acknowledgement of Dangerous Activity and Waiver (Modern Pentathlon All Events Swimming, Fencing, Riding, Combined Event) Full Name of Pentathlete (and of guardian if under 18 years).... Address. State... Post Code Date of Birth.. In consideration for being permitted to participate in any way in the Modern Pentathlon Events, I, the undersigned, understand, acknowledge and accept that: 1. The Modern Pentathlon Events involve the real risk of serious INJURY or even DEATH from various causes including but not limited to over exertion, equipment failure, dehydration, accidents with other participants, spectators, riding, course or weather conditions. 2. The Modern Pentathlon Riding Event is a dangerous activity and horses can act in a sudden and unpredictable (changeable) way, especially if frightened or hurt. 3. 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 the Modern Pentathlon Riding Event, or at any point during an Event. 4. I agree to wear an approved helmet at all times whilst participating in the Modern Pentathlon Riding Event. 5. I am fully responsible for my own safety, including in relation to any and all equipment and protective clothing for the purposes of the Fencing and any other of the Modern Pentathlon Events. 6. I agree to follow the direction 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 and my immediate removal from the Modern Pentathlon Events no matter where that may occur. 7. I accept all risks necessarily flowing from my participation in the Modern Pentathlon Events, and I release Modern Pentathlon Queensland Inc and any organisers or officials associated directly and indirectly with the conduct of the Modern Pentathlon Events of all claims, demands and proceedings arising out of my participation in the Modern Pentathlon Events. I have had sufficient opportunity to read this Dangerous Activity Acknowledgement and Waiver and fully understand its terms and sign it freely and voluntarily. Dated: / / Signature of Pentathlete:.. 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 child s involvement or participation in the Modern Pentathlon Events Dated: / / Signature of Guardian:.