*(Must be a WCRMHC member to ride horseback to the winery) 4/30/17 (insert number attending)

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1 WEST COAST ROCKY MOUNTAIN HORSE CLUB CAMPOUT April 27-May 2, 2017 Sign Up Form One Form Per Family (If traveling together but have different addresses make separate form for each person) Please Check Member Status: Single Family *Junior *Juniors 17 and under are required to wear a helmet and boot with a heel when mounted on a horse at all times. Those that don t comply may be asked to leave with no refund. This is for safety & insurance. (WCRMHC 2017 Membership is Mandatory to participate in all activities) List Name: Rider Non-Rider 2 nd Name: Rider Non-Rider 3 rd Name: Rider Non-Rider 4 th Name: Rider Non-Rider 5 th Name: Rider Non-Rider Last Name First Name Size T-Shirt: Last Name First Name Size T-Shirt: Last Name First Name Size T-Shirt: Last Name First Name Size T-Shirt: Last Name First Name Size T-Shirt: (See T-Shirt Size Chart Next Page 2) 6. Contact Phone: Home( ) Cell ( ) 7. address: (PRINT) 8. Mailing Address: 9.Wine Ride & Luncheon on Sunday *(Must be a WCRMHC member to ride horseback to the winery) 4/30/17 (insert number attending) Rider Non-Rider 10. Camping/Not Camping? Camping (in rig with ) Not Camping 11. If camping, Number and gender of Horse(s)you are bringing 12. Number of Corrals you need: One corral per Adult or Junior included in camping fee. (Bring & set up your own corral for $15 extra) 13. If camping, are you bringing a dog? (check one)no Yes, If yes:> Mare Gelding Stallion More info if needed: Northcote corral(s)requested: (number) I am bringing my own portable corral for my second horse and agree to pay $15 extra. Signed Dog Rules: I agree to comply with the following: 1. Keep dog(s) on leash(s) 2. No dog(s) on trails 3. Okay to take dog(s) for a walk beyond canyon gate on street on leash. 4. No Dogs on Northcote Patio or at caterer s kitchen and meal area. Signed If you are the rig driver complete If passenger(s), Skip 14 through Type of Rig and Size: Motorhome Gooseneck Bumper Pull Trailer Total Rig Length (feet) 15. Electricity Hook Up (if possible) Yes No 16. Arrival Date & Approx. Time: Date Time 17. Departure Date: Date Time 18. Northcote s Travel Trailer* Contact for reservations. (Separate cleaning Fee Paid to Gloria). 19. Horse Trail Riding Group Rides: Please tell us what type of ride, the length of ride and if you or horse have safety concern the Ride Leader should be aware for example: horse kicks or doesn t cross water or rider allergic to? *Limited accommodations require reservation with Gloria. You will need to arrange with her directly. (Bring your own sleeping bag, pillow & towels.) Trailers have elec., refrigerator, microwave and water. Please Riders Names: Walk Only: : [ ] Ride Length: Walk/Gait Only: : [ ] Ride Length: Walk/Gait/Canter : [ ] Ride Length: Please list any safety concern: 1

2 Mindy Smiths s Challenge Horse Trail Course Saturday 4/29/ Do you plan to ride in Saturday obstacle course? Trail Course Sign Up: Multiple course sign-up is OK (If needed, duplicate this page if signing up for more than 4 riders) 21.Pre-sign up for Trail Course Saturday. 4/29/17 (*Juniors Under 18 Must Wear a Helmet and Boot with a Heel) **All Riders must wear a Helmet on the Obstacle course. 22.Pre-sign up for Trail Course Saturday. 4/29/17 (*Juniors Under 18 Must Wear a Helmet and Boot with a Heel) **All Riders must wear a Helmet on the Obstacle course. 23. Pre-sign up for Trail Course Saturday. 4/29/17 (*Juniors Under 18 Must Wear a Helmet and Boot with a Heel) **All Riders must wear a Helmet on the Obstacle course. 24. Pre-sign up for Trail Course Saturday. 4/29/17 (*Juniors Under 18 Must Wear a Helmet and Boot with a Heel) **All Riders must wear a Helmet on the Obstacle course. 25. If camping, but not riding in obstacle course, would you be interested in being a judge or helper at the Obstacle Course? Yes No If No, go to # 25 Pre-Sign Up for Trail Obstacle Course(s): Challenge Horse Trail Course Saturday 4/29/17 (Now at Mindy Smith s New Location 1865 Hi Mountain Rd.) Rider First name Rider last name (circle one) Male or Female Horse Name Breed of Horse (circle one) Mare Gelding Stallion Rider Age Category Please Check one: Youth (List age Under 18) (Adult Rider) (Beginning Rider) Rider First name Rider last name (circle one) Male or Female Horse Name Breed of Horse (circle one) Mare Gelding Stallion Rider Age Category Please Check one: Youth (List age Under 18) (Adult Rider) (Beginning Rider) Rider First name Rider last name (circle one) Male or Female Horse Name Breed of Horse (circle one) Mare Gelding Stallion Rider Age Category Please Check one: Youth (List age Under 18) (Adult Rider) (Beginning Rider) Rider First name Rider last name (circle one) Male or Female Horse Name Breed of Horse (circle one) Mare Gelding Stallion Rider Age Category Please Check one: Youth (List age Under 18) (Adult Rider) (Beginning Rider) Please List Your Name: Judge: Helper: Other Please list: 2

3 WCRMHC April 27-May 2, 2017 Camping Fees Form Print Name: WCRMHC Camp-Out Adult WCRMHC Member Rider Campout (Includes 5 nights, 6 days camping, swimming, Jacuzzi, trail rides. Rocky Week T- Shirt, National Rescue Dog Search Foundation Demonstration, Mindy Smith s Obstacle Course, Lot 40 riding trail maintenance fee. 6 Catered meals; Dinner Friday, Saturday The Big breakfast, make your own lunch after breakfast, Western Dinner/Dance with The Instigators Band, Sunday AM light breakfast, Devotional and Winery Wine Tasting & Lunch Ride. 1 Corral Per person Junior WCRMHC Member rider campout (includes all as above. Must be camping with supervising and responsible adult) Name of Adult Supervisor: Camping Non-Rider (ie: Spouse) Includes all meals & T-shirt Name: Not Camping at the Northcote s With Horse WCRMHC Member, Not Camping at Northcote s. Includes all of above, may ride/participate in all events and rides (No corrals at Northcote s). Either trailer in each day or camp at prearranged local neighbor s property. Mindy Smith s Obstacle Course Only Sat. 5/29/17 WCRMHC Member, Compete in one day event Obstacle Course. Sign up and trailer to Mindy Smith s Ranch located at1865 Hi Per Person $ $ $ $ $40.00 Mountain Road, AG. Prizes will be awarded! Western BBQ Dinner & Dance Sat. Only 5/29/17 Includes BBQ Dinner & Dance Northcote Ranch $40.00 Winery/Luncheon Ticket Sunday Only 5/30/17 Non-camping WCRMHC adult member rider or non-member (non-rider) Winery, Wine Tasting & Lunch. (Sunday ONLY) Name: $55.00 Extra T-Shirt (Indigo Blue) Please Indicate Size Needed $15.00 Logo Hat (See Picture below) One size fits all $15.00 Extra Horses/Corrals Bring your own Portable Corral (for your second horse) $15.00 Northcote Corral for second horse (if room is available) $25.00 QTY Total Sub Total Above: (Add Late Fee $50 per person if postmarked after Tuesday, April 10, 2017): (Make Check Out to WCRMHC ) Total Due: *If traveling with a family, please make out one check payable to WCRMHC and staple entries together Form & Check postmarked and due by April 10, 2017 Enrollment form deadline must be adhered to in order to secure your desired shirt sizing. (Late Fee is additional $50.00 per person. No Refunds for cancellations after April 17, 2017) Send to: Phyllis Rockwood (WCRMHC April Event 2017 ) 1095 Shannon Lane Arroyo 3 Grande, CA (Please include the two Signed Waivers Below (1 waiver per Family okay) with Check & Sign Up Form)

4 WCRMHC Entry Comes with T Shirt See Chart Size - Need Size Info by 4/10/17 for ordering. (Logo Hat Is Extra $15) 4

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9 Consent, Waiver and Assumption of Risk Agreement Adult Name: Address: City, ST, Zip: Phone: I, the above named rider understand that trail riding involves being in remote areas for extended periods of time, far from communications, transportation and medical facilities; that there are many natural and man made hazards, which cannot be anticipated. I acknowledge that horses can be excitable, difficult to control, and unpredictable, and that accidents can happen to anyone at any time. I, in consideration of accepting to ride, do hereby waive liability for myself, my heirs, executors and administrators from all and every claim of injury, damage, or loss to myself, those of whom I am in charge of, my livestock and my properties. I agree to abide by the rules, conditions and regulations of the West Coast Rocky Mountain Horse Club. I have read and understand the contents of the above. Date: Signed: **************************************************************************************************************************************** Adult Name: Address: City, ST, Zip: Phone: I, the above named rider understand that trail riding involves being in remote areas for extended periods of time, far from communications, transportation and medical facilities; that there are many natural and man made hazards, which cannot be anticipated. I acknowledge that horses can be excitable, difficult to control, and unpredictable, and that accidents can happen to anyone at any time. I, in consideration of accepting to ride, do hereby waive liability for myself, my heirs, executors and administrators from all and every claim of injury, damage, or loss to myself, those of whom I am in charge of, my livestock and my properties. I agree to abide by the rules, conditions and regulations of the West Coast Rocky Mountain Horse Club. I have read and understand the contents of the above. Date: Signed: ***************************************************************************************************************************************** WAIVER FOR A MINOR: I hereby give consent for my child (children), a minor(s), named to ride and certify that I have read the above waiver and that the waiver is deemed a part hereof and hereby accept responsibility there under for the participation of said minor in horse activities. I do further authorize anyone; the owners, management or supervisory personnel of the West Coast Rocky Mountain Horse Club to consent on my behalf to an emergency medical treatment for my child and release any such person giving such consent from any liability for their decision. Date: Signed by Parent: Print Name: Legal Guardian: Emergency Phone Number: 9

10 RANCHITA ESTATES ROAD I HOMEOWNERS ROAD MAINTENANCE ASSOCIATION Consent, Waiver and Assumption of Risk Agreement (Must be signed by each Adult Rider) Name(s): Street Address: City, ST, Zip: Phone: I, the above named rider(s) understand that trail riding involves being in remote areas for extended periods of time, far from communications, transportation and medical facilities; that there are many natural and man made hazards, which cannot be anticipated. I acknowledge that horses can be excitable, difficult to control, and unpredictable, and that accidents can happen to anyone at any time. I, in consideration of riding on or alongside Road 1 located in Ranchita Estates, do hereby waive liability for myself, my heirs, executors and administrators from all and every claim of injury, damage, or loss to myself and those of whom I am in charge of, my livestock and my properties. I have read and understand the contents of the above. Signed: Date: Printed Name: Signed: Date: Printed Name: RANCHITA ESTATES ROAD I HOMEOWNERS ROAD MAINTENANCE ASSOCIATION Child s/children s: Consent, Waiver and Assumption of Risk Agreement For Minor Child Rider Name(s) Age: Name(s) Age: Name(s) Age: I, the below named parent and/or legal guardian, understand that trail riding involves being in remote areas for extended periods of time, far from communications, transportation and medical facilities; that there are many natural and man made hazards, which cannot be anticipated. I acknowledge that horses can be excitable, difficult to control, and unpredictable, and that accidents can happen to anyone at any time. I, in consideration of my child(s) above named riding on or alongside Road 1 located in Ranchita Estates, do hereby waive liability for myself, each child named, my heirs, executors and administrators from all and every claim of injury, damage, or loss to myself, those of whom I am in charge of, my livestock and my properties. I have read and understand the contents of the above. Parent or Legal Guardian Signature Date: Print Name: Emergency Phone #: 10