Dressage at Blue Goose

2012 USEF/USDF Licensed Shows

Recognized by the United States Equestrian Federation as a Level 2

Dressage Competition

Official Qualifying Competition for:

2012 Great American Insurance Group/USDF Regional Dressage Championships

2012Colonel Bengt Ljungquist Memorial Championships

2012 Dover/USDF Adult Amateur Medal Program

Secretary/Manager Licensee Darcy Miller-Brown Blue Goose Stable, LLC

210 White Horse Rd Darcy M Miller-Brown

Cochranville PA 19330 Cochranville, PA 19330

610~ 869~ 2233 BlueGooseStable@verizon.net

BlueGooseStable@verizon.net www.BlueGooseStable.com

www.BlueGooseStable.com

Veterinarian On Call Farrier On Call

Hayden Luke

Deepwater, NJ 443 – 466 - 6078

EMT on Site

Karen Boland

COMPETITORS ARE ENCOURAGED TO ENTER ONLINE ATWWW.EQUESTRIANENTRIES.COM. A $10 DISCOUNT WILLBE GIVEN TO THOSE ENTERING ONLINE

Dressage At Blue Goose Dressage at Blue Goose II Dressage at Blue Goose III

Wednesday

May 16, 2012

Wednesday

July 4, 2012

Wednesday

August 8, 2012

USEF/USDF

Competition # 317167

USEF/USDF

Competition # 317556 USEF/USDF

Competition # 327685

Judge:

Heather Mason (S-NJ)

Lebanon, NJ

Amy Gimble (r-NJ)

Judge:

Debbie Rodriguez (S-VA)

Williamsburg, VA

Lisa Schmidt (R-NJ)

Hampton, NJ

Judge:

Marilyn Heath (S-FL)

Naples, FL

Susan Jones-Sinelnik (r-NJ)

Berlin, NJ

TD:

Val Bastinelli (r-PA)

Martins Creek, PA

TD:

Nancy Lowey ( r – VA)

Orange, VA

TD:

Karen Vinsant (r-VA)

Gladstone, VA

Opens:

March 5, 2012 Opens:

May 1, 2012 Opens:

June 9, 2012

Closes:

April 20, 2012 Closes:

June 8, 2012 Closes:

July 9, 2012

Classes:

Every class offered herein which is covered by the rules and specifications of the current USEF

Rule Book will be conducted and judged in accordance therewith

1. USDF Intro A 15. Third Level Test 1

2. USDF Intro B 16. Third Lv Test 2 (BLM)

3. USDF Intro C 17. Third Lv Test 3 (GAIG/USDF-Q)

4. Training Lv Test 1 Opportunity 18. Fourth Level Test 1

5. Training Lv Test 2 Opportunity 19. Fourth Lv Test 2 (BLM)

6. Training Lv Test 1 20. Fourth Lv Test 3 (GAIG/USDF-Q)

7. Training Lv Test 2 ( BLM) 21. Prix St. Georges – Open/BLM/GAIG/USDF

Qual*

8. Training Lv Test 3 (GAIG/USDF-Q) 22. Intermediare I – Open/BLM/GAIG/USDF Qual*

9. First Lv Test 1 23. Intermediare II – Open/BLM/GAIG/USDF Qual

10. First Lv Test 2 ( BLM) 25. Grand Prix – Open/BLM/GAIG/USDF Qual*

11. First Lv Test 3 (GAIG/USDF-Q) 26. TOC: FEI / USEF Young Horse

12. Second Level Test 1 27: TOC: Para-Equestrian (20 x60 ring)

13. Second Lv Test 2 (BLM) 28. TOC Para – Equestrian (20 x 40 arena)

14. 14. Second Lv Test 3 (GAIG/USDF- Q)

(USDF/Dover Adult Amateur Medal)

29. TOC: FEI – any unlisted FEI Test (Yr rider Team

& Jr Team only BLM, GAIG-Q if applicable)

Please note for class 29: No test that is previously offered as qualifying on that day may be ridden as qualifying in that class also.

This class is listed solely for the purpose of offering FEI tests that are not offered as their own class.

Fees:

Intro and Opportunity classes

$35.00 per test

(note: Intro and opportunity classes are exempt

from all horse ID and membership

requirements)

USEF Fee: ($8.00 USEF Fee + $8 Drug Fee)

$16.00 per horse

Training thru Fourth Level:

$45.00 per test USEF Non-Member Fee ( If applicable):

$30.00 for each NM rider, owner, or trainer

FEI Classes:

$55.00 per test USDF Non-Member Fee ( if applicable):

$25.00 for each NM rider, owner

GAIG Qualifying Classes:

Additional $10.00 per class

Office Fee:

$30.00 per entry (non refundable)

$ 20.00 (non refundable) If entering online at

www.equestrianentries.com

Non – Negotiable Check Fee: ( if applicable)

$30.00

Entry Change Fee:

$15.00 if change is possible and before closing

date

Non-Competing Horse Fee:

Must provide signed entry blank, coggins, and

wear bridle number at all times. No USEF /

USDF fees apply

$40.00

Late Fee: ( for any entry RECEIVED after

the closing date)

$30.00

DEFINITIONS AND ELIGIBILITY:

BLM: Results of these classes are used to qualify horse and rider combinations for the 2012

Colonel Bengt Ljungquist Memorial Championships. Riders must be a member of a

participating GMO. For rules go to www.cblm.org

GAIG/USDF –Q: If entering a Great American Group /USDF Qualifying class, enclose

additional $10 fee. Copies of current USEF and USDF participating or business membership

cards for rider and owner as well as USDF / USEF Horse Registrations must be included with

entry.

Adult Amateur: Adult Amateur entries must include a copy of their current USEF

membership card declaring them such.

JR/YR: Individuals are eligible to enter as Juniors until the end of the calendar year in which

they reach the age of 18. Individuals are eligible to enter as Young Riders from the beginning of

the calendar year in which they reach the age of 16 until the end of the calendar year in which

they reach the age 21. Competitors shall compete as Adults from the beginning of the calendar

year in which they reach age 22. (DR19.3) Riders who are 16 and 17 may compete as either

juniors or Young Riders. Date of Birth must be noted in designated spot on entry form.

USDF Horse Numbers: USDF requires all competing horses to have a Horse Identification

Number (HID) for the purpose of tracking scores. A HID can be obtained from USDF online for

a fee $25. If your horse is Lifetime Registered that number is your horse HID. Competitors are

strongly urged to acquire this number prior to the competition. Go to www.usdf.org

USEF Horse Numbers: USEF requires all competing horses to have an Identification

number (ID). USEF and USDF have reached an agreement to share HID/ID numbers. Horses

must be fully registered with both the USEF and USDF to be eligible to participate in the

GAIG/USDF-Q classes.

ATTENTION COMPETITORS Each competitor is responsible for for supplying management with correct association numbers (USDF, United States Equestrian Federation) for horse, owner, rider, and trainer, before the day(s) of the competition. The scores of competitors who fail to supply correct numbers may not be counted toward national awards.

USEF MEMBERSHIP STATEMENT Life, senior active and junior active members shall be eligible to participate in all classes at Regular Competitions, Eventing Competitions at the Preliminary Level or above and Combined Driving Competitions at the Advanced Level, Dressage, Reining and Vaulting Competitions and Endurance Rides. A nonmember may participate as a handler, rider, driver, owner, lessee, agent, coach or trainer at Regular Competitions, Eventing Competitions, Dressage Competitions, Reining Competitions and Combined Driving Competitions upon payment of a $30 nonmember registration fee. Participants in the following classes are exempted from the Requirements of this rule: 1) leadline; 2)exhibitions; 3) games and races; 4) classes for 4-H members; 5) walk trot and academy classes (academy classes are classes limited to horses used regularly in a lesson program); 6) USDF introductory level tests, pas de deux and quadrille classes; 7) NRHA Endorsed Reining Competitions. 8) Opportunity classes, 9) citizens of other nations who have proof, in English, of current membership in good standing of their own National Federation, 10) USEA beginner novice division; and 11)

assistant handlers in Dressage Sport Horse Breeding classes.

Entries must include:

1. 2012 USDF Region One Entry form only. Must be one page /double sided with

original signatures. No photocopied signatures. FILL OUT ENTRY IN ITS

ENTIRETY.

2. $30.00 Office Fee per entry.

3. $16.00 USEF Federation Fee per entry. ( Includes $8 for Drugs and Medication Fee and

$8 Federation fee)

4. Class Fees

5. Negative Coggins dated with in one year of the show date. Horse name on the entry

blank must match coggins report and USEF / USDF documentation. USEF GR 907.3

6. Copies of USEF and USDF Membership cards for Rider, Owner, Trainer, Horse, and

Coach (if applicable) or USEF/USDF non member fees.

7. Include a LEGIBLE e-mail address on entry form. This will be used to send

confirmations as well as ride times.

8. Make checks payable to: BLUE GOOSE STABLE, LLC. Checks returned for

insufficient funds will incur a $35 fee. The entry will be placed on waiting list until

another form of payment is secured. No exhibitor is permitted to show until all fees are

paid. Competitors will be subject to USEF Non –negotiable funds Rule (GR 1508.1)

9. REFUNDS: Cancellations prior to closing date will be refunded, less office fee. NO

REFUNDS (including overpayments) WILL BE GIVEN AFTER CLOSING DATE

FOR ANY REASON. Management reserves the right to cancel any classes due to

hazardous weather, Acts of God, accident, or emergency. Every effort will be given to

reschedule with priority given to Qualifying classes. No REFUNDS for cancellations due

to hazardous weather, Acts of GOD, accidents or emergencies.

10. POST ENTIRES: Accepted if space available. A $30.00 additional fee per entry applies.

11. Entries must be RECEIVED by the closing date. No telephone, e- mail, or faxed

entries will be accepted.

12. Incomplete entries will be placed on wait list until all documents are received.

13. Non Competing Horses: Must submit completed entry form with signatures, a current

negative coggins and $40.00 fee prior to show date.

14. Entry must include EMERGENCY CONTACT NUMBER in the space provided.

MANAGEMENT RESERVES

THE RIGHT TO RETURN

ENTRIES THAT ARE

INCOMPLETE OR

INACCURATE

USEF FEES AND REQUIREMENTS:

1. USEF membership information for EACH Rider, Owner, Trainer, Horse,

Coach ~ if applicable, is required on your entry form. If an exhibitor does

not submit the proper membership documentation to the competition and the

competition can not verify such information, (with the exception of

Federation measurement cards), the exhibitor will be responsible to pay a

$30 non member fee with is non refundable. ( GR 1309, 2.b)

2. For USEF Non- Members: A $30 fee will be collected for EACH rider,

owner, trainer, coach ~ if applicable.

3. USEF HORSE ANNUAL OR LIFETIME REGISTRATION IS

REQUIRED FOR QULAIFYING CLASSES.

4. The USEF Horse ID or Horse Recording number is required on your entry

form. If you do not have a Horse ID, you may apply for one before the

competition www.usef.org , provide your USDF Horse HID number as proof

for Horse ID ( GR 1101)

CONDUCT OF SHOW: All standard USEF Rules will apply. Please refer to Standard Rules listed in Omnibus or your USEF Rulebook. Show Management reserves the right to limit entries, add or divide classes, to add or substitute judges, to cancel awards and prizes and/or make whatever changes are required by circumstances to the competition specifications listed herein. Show Management reserves the right to cancel classes insufficiently filled and to refuse or require withdrawal of an entry for cause deemed sufficient by Show Management.

At anytime while mounted on the competition show grounds, all riders under the age 18, all riders while on

horses competing at national level tests, all riders competing in Para-Equestrian test, and all riders while on

non-competing horses, must wear protective headgear as defined by this rule and otherwise in compliance

with GR801. When a horse is competing in both national and FEI levels or tests (e.g. Fourth Level and PSG),

the rider must wear protective headgear at all times when mounted on that horse on the competition grounds

and during tests. Any rider violating this rule at any time must immediately be prohibited from further riding

until such headgear is properly in place. Any other exhibitor may wear protective headgear at any level of

competition without penalty from the judge. Protective headgear is defined as a riding helmet which meets of

exceeds ASTM ( American Society for Testing and Materials)/SEI (Safety Equipment Institute) standards for

equestrian use and carriers of the SEI tag. The harness must be secure and properly fitted.

(GR120.5)

USDF FEES AND REQUIRMENTS:

1. The USDF membership information for EACH Rider, Owner, Horse is

required on your entry form.

2. For each USDF non-member (NM) owner/lessee and USDF NM rider there

will be a fee of $25 and a USDF NM form that must be collected by the

competition. In addition, there will be a $5 affidavit fee if the person cannot

provide a copy of their NM ID card.

3. The USDF Horse ID (HID) or Lifetime Registration is required on your

entry form. If you do not have a HID or Lifetime Registration number, you

will be required to fill out either a HID form or Lifetime form and pay

appropriate fees. If you have a HID or Lifetime Registration and cannot

provide proof , you will be required to fill out an affidavit and pay an

additional $5 fee to USDF before you are allowed to compete. USDF Horse

Lifetime Registration is required for Qualifying Classes.

Other Important Notes:

1. Specify on entry form OPEN/AA/Jr/YR. Classes may be split if entries warrant. Adult

Amateurs MUST include a copy of their current USEF Membership card proving AA

status.

2. Please specify if Qualifying Ride on entry form. Enclose additional $10 fee plus class

fee. Rider and Owner must be a USDF and USEF member; horse must be Lifetime

registered with USDF and Annual or Lifetime Registered with USEF.

3. Dover Medal: Specify Dover Medal AA on entry form. Rider must provide USEF AA

membership card and copy of USDF GMO or Participating membership card. Medal is

awarded to the Adult Amateur with the highest score in Class 14, earning a minimum

score of 60%.

4. No – Shows: If competitor fails to notify the competition secretary of their intention to

scratch a test (ie: is a no show), competition management reserves the right to fill all of

that competitors subsequent ride times. USEF Rule 126.1(3)b

5. Test Versions: Current Editions of USDF Intro, USEF Training –

Fourth Level and any FEI and Para tests will be used.

BRIDLE NUMBERS MUST BE WORN AT ALL

TIMES ON THE SHOW GROUNDS. THIS

INCLUDES NON-COMPETING HORSES

6. Horse Substitutions: Riders may substitute horses once they have entered only upon presentation

of a vet certificate for the incapacitated horse, or a bill of sale, and ONLY in the classes in which

the first horse was entered. The secretary MUST be notified at least 24 hours prior to the

class(es) taking place AND a NEW entry form must be completed prior and a office fee must be

included.

7. Class and Judge Changes: Management reserves the right to split, combine, delete, or add

classes. Management also reserves the right to add or substitute judges or make any changes

required by circumstances.

8. Waiting List: A wait list will be established if necessary and entries will be accepted on a first –

come, first serve basis.

9. Stabling: Limited stalls may be available at an off site facility. Contact Show secretary to check

availability.

10. Sharps containers: A sharps container will be located at the secretary stand. Competition

Management may fine any individual, including trainers, exhibitors, owner, or their agents,

up to $100 for improper disposal of needles or other sharp disposable instruments.

11. DOGS: Dogs must be kept on a leash and in the parking area away from the secretary stand,

warm up arena, competition arena and food-stand.

12. Damages to Third Parties: All owners and competitors are personally responsible for damages

to third parties caused by themselves, their employees, their agents, or their horses. They are

therefore strongly advised to take out third party insurance providing full coverage for

participation in equestrian events.

Warning: Under Pennsylvania law an equine professional and equine

activity sponsor is not liable for an injury to or death of a participant

in equine activities resulting from the inherent risks of equine

activities.

Hold Harmless Clause: Understanding that horse sports may be hazardous and dangerous,

even leading to permanent injury or death, each owner, rider,

spectator, and other participant assumes any and all risk of loss or

injury and agrees to hold harmless, regardless of negligent acts or

omissions Blue Goose Stable, LLC, the show management, show

committee, and all horse show personnel.

Arena Footing and Arenas:

1. Competitions arenas are Standard Dressage Arenas (20 x 60 m) with sand

and permaflex footing.

2. Warm – up arena is sand.

3. NO WARM UP or LUNGING in PARKING AREA

4. Lunging is permitted in round pen at bottom of driveway to the right.

Times & Office hours :

1. The show office will be open at 12:00 noon on Tuesday before the show and

at 7 am on show day.

2. Phone number during the show 610 – 999 – 5231

3. Provisional Ride Times will be posted at www.BlueGooseStable.com by

Tuesday the week prior to the competition date.

4. Official ride times will be posted at 12 noon Tuesday the day before the

show. It is the rider’s responsibility to check their official ride time for

changes upon their arrival at the show.

a. Ride times may change up until one hour before the start of the

competition. Any and all changes will be posted at the secretary’s

stand.

b. Classes may be scheduled out of order.

c. Dressage classes must be run in their entirety.

d. Failure to enter the arena at your specified time will result in

elimination.

Scores: It is the responsibility of the competitor to verify the accuracy of all

scores. Scoring errors must be reported to the Show Secretary within one hour of

the official posting of the scores from the last class of the show day.

Awards:

1. Ribbons thru 6th

place

2. Hi Score awarded at each level with three or more riders showing.

Foreign Competitors: Non –US citizens and Foreign Competitors must provide

proof, in English, of current membership in good standing in their respective

National Federation, or hold a current membership in good standing with USEF.

Motorized Vehicle Statement

In accordance with GR1301.7:

Minors who do not have a valid driver's license which allows them to operate a motorized vehicle in the state in which they reside will not be permitted to operate a motorized vehicle of any kind, including, but not limited to, golf carts, motorcycles, scooters, or farm utility vehicles, on the competition grounds of licensed competitions. Minors who have a valid temporary license may operate the above described motorized vehicles as long as they are accompanied by an adult with a valid driver's license. Violations of this rule will be cause for sanctions against the parent(s), guardian(s) and/or trainer(s) who are responsible for the child committing the offense. Penalties may include exclusion of the child, parent(s), guardian(s), and/or trainer(s) from the competition grounds for the remainder of the competition and charges being filed against any of the above individuals in accordance with Chapter 6. Wheelchairs and other mobility assistance devices for

individuals with disabilities are exempt from this rule.

Mow the fields. Haul the hay. Paint the barn — and the

house. Re-order supplements and office supplies.

Get new tires and a full service check. Make sure

we’re covered on the road and in the ring. Get ready

for the big competition. Win! Rent a car and drive to

the coast. Take a vacation. Relax! You don’t

have to bet the farm to check off this season’s most important tasks. For details on

how you can save big with USEF MemberPerks, visit usef.org

or call one of our Customer Care agents at 859.258.2472.

equestrian

USEF Competition Name: USEF#:Competition Division(s) and Rating(s):

09/10

USDF Membership Benefits: USDF is dedicated to education, the recognition of achievement, and promotion of dressage. For details on member benefits, including educational programs, awards, and other opportunities, refer to the USDF Competitor & Member Guide or the USDF website at www.usdf.org.

Membership Requirements for USEF-licensed/USDF-recognized Competitions: Owners and riders, including foreign riders and owners who are not residents of the US, wishing to participate in a USEF-licensed/USDF-recognized competition as a rider or owner/lessee, must have either a USDF Group Membership, Participating Membership (PM), or have a USDF Non-Member (NM) identification number and pay the USDF NM fee. (Note: USDF business members can own horses but cannot compete as riders with their USDF BM.) Individuals cannot compete at a USEF-licensed/USDF-recognized competition with a USDF Education Membership.

Horses competing at USEF-licensed/USDF-recognized competitions must have either a USDF Horse Identification (HID) number or a USDF Lifetime Horse Registration (LHR). Proper credentials or verification certificates must be presented to the competition secretary.

Riders and owners wishing to participate in a USEF-licensed/USDF-recognized competition, and not able to present the competition secretary with verification of a USDF membership or NM identification, and USDF LHR or USDF HID, must complete a USDF Competition Affidavit Form and pay the $5 affidavit filing fee. A copy of a completed affidavit form from another competition may also be used for verification purposes for up to 60 days. (Exception: Affidavits cannot be used at Great American Insurance Group/USDF Regional Dressage Championships.) Exceptions:

• Horses competing only in Individual Breed Classes (IBCs) at DSHB competitions, sires and dams of horses in DSHB group classes, where those sires or dams are not actually competing in the same competition, horses competing only in breed restricted dressage or DSHB classes at Regular Competitions (e.g. all Arabian, all Friesian, or all Morgan classes), or in USDF Introductory Level tests, Pas de Deux, Quadrille, FEI ParaEquestrian classes, are exempt from this requirement. Also exempt are horses ridden in leadline, exhibitions, games and races, classes for 4-H members, walk-trot, academy and opportunity classes.

• Riders and owners/lessees competing only in classes which are exempt from the USDF HID requirements are also exempt from the USDF NM identification number and NM fee requirements. Also exempt are handlers of horses competing in DSHB In-Hand or Group classes.

Memberships Defined Participating Membership (PM): A membership issued to an individual directly by USDF. The membership year is December 1 through November 30. PMs are available for 1-year ($75), 5-years ($300), or life ($1,500). A USDF Youth Participating Membership (YPM) is available for individuals who have not reached their 21st birthday by December 1 of the current membership year ($60). A PM allows the member to compete at USEF-licensed/USDF-recognized competitions and to participate as a rider and/or owner/lessee for all Adequan®/USDF Year-End Awards, Great American Insurance Group/USDF Breeders’ Championship Series Finals and the Great American Insurance Group/USDF Regional Dressage Championship program. Group Membership (GM): A membership issued to an individual by USDF when the member name and dues are submitted to USDF through an affiliate Group Member Organization (GMO). The GM year begins December 1 and ends November 30. A GM allows the member to compete at USEF-licensed/USDF-recognized competitions and participate in the USDF Rider Awards program. Business Membership (BM): A membership that runs December 1 through November 30 and is issued to a business or organization directly by USDF. The USDF BM ($200) offers a wider variety of advertising benefits. BMs satisfy requirements of horse ownership only. Education Membership (EM): A membership issued to an individual directly by USDF. This online education only membership expires 12 months after the date joined. This membership type does NOT allow an individual to compete at a USEF-licensed/USDF-recognized competition. Non-Member (NM) Identification Number: For each USDF NM owner/lessee and USDF NM rider there will be a USDF NM fee of $25 and a USDF NM form per competition that must be collected by the show secretary and submitted to USDF along with the USDF Report of Fees document and the $5 affidavit fee if the person cannot provide a copy of their USDF NM card. Owners/lessees or riders exempt from the NM number requirements are also exempt from paying the USDF NM fee. If there are multiple owners of a horse and all are NMs, only one of the owners must pay the NM fee. If the horse has at least one owner who is a current USDF member there is no NM fee assessed. Competition management will be invoiced for all applicable USDF NM fees not received with the USDF post competition paperwork, along with a report listing all USDF NMs. Competition management is then required to submit the NM fees within 30 days to the USDF. An individual with a USDF NM identification number is not eligible for any USDF membership benefits. Once a USDF NM number has been assigned, a USDF NM card can be obtained from the USDF website. Horse Identification (HID) Number: A one-time tracking number for horses ($25). Scores earned by a horse with an HID number will be recorded, but will NOT be counted towards Adequan®/USDF Year-End Awards. A horse with an HID number is not eligible to compete in Great American Insurance Group/USDF Regional qualifying or championship classes or Great American Insurance Group/USDF Breeders’ Championship Series Finals. An HID number can be upgraded to a Lifetime Horse Registration (LHR) for a fee of $70. If a horse has a USDF LHR it does not need an HID number. An HID number is a one-time fee that does not need to be renewed. Lifetime Horse Registration (LHR): A horse with an LHR ($95) is eligible for Adequan®/USDF Year-End Awards, and eligible to compete at Great American Insurance Group/USDF Breeders’ Championship Series Finals and Great American Insurance Group/USDF Regional qualifying and championship classes, assuming requirements for the owner and rider are met. If a horse has an LHR it does not need an HID number. An LHR does not need to be renewed.

How to Join USDF Applications for USDF Participating Membership (PM), Business Membership (BM), Horse Identification (HID) number, and Lifetime Horse Registration (LHR) may be found in the following locations:

• On the USDF website: www.usdf.org. You can submit the application online or download the form and fax or mail it to the USDF office. • In the show office at USEF-licensed/USDF-recognized competitions classified by USEF as Dressage Competitions, and Regular Competitions which are

open to all breeds. • By calling or writing the USDF office at (859) 971-2277, 4051 Iron Works Parkway, Lexington, KY 40511

The effective date of membership is the date the form and correct fees are received in the USDF office or, if applying at a competition, the date accepted by the competition secretary, provided the application is signed and dated by the competition secretary, member, and/or horse owner on that same day.

This competition is recognized

by USDF for 2012

2012 DRESSAGE COMPETITION ENTRY FORM Effective December 1, 2011, use this form for entering USEF/USDF Licensed Dressage Competitions held in USDF Region 1 (PA, NJ, DE, MD, VA, NC, WV) Competitors are responsible for duplicating their own additional copies of this entry form. This is a 2-sided form; please make 2-sided copies. Other versions of entry forms may not be accepted by Region 1 competitions. TYPE OR PRINT CLEARLY -- ONLY ONE HORSE / RIDER or HANDLER PER ENTRY FORM Enclose copy of all 2012 USEF Membership Cards (Rider/Handler, Owner/Agent, Trainer, Coach) or verification.

Official Use Only Bridle No.

Competition Name:

_____________________________________________ Competition Date(s): ________________ NAME OF HORSE (Horse MUST be named) BREED COUNTRY (Where Bred) SEX HEIGHT COLOR AGE DOB

Date of Coggins (must attach copy):

Breed Registration Number:

Check here If this horse is for sale and you want this to be listed in the Program _____

Sire: Dam: Dam’s Sire: For Dressage Sport Horse Breeding (DSHB) classes, Sire, Dam, Dam’s Sire & Breeder names required for ALL breed registered horses & recommended for others. Breeder:

Rider/Handler: __________________________________ Primary Phone: _______________Alternate Phone: _______________ Rider’s Address: _________________________________________________________________________________________ Rider/Handler E-Mail: _____________________________________________________________Citizenship*: ______________ Owner: _____________________________________ Primary Phone: ________________Alternate Phone: _________________ Owner’s Address: __________________________________________________________E-Mail: ________________________ Trainer: ______________________________ Trainer’s Address:___________________________________________________ Coach: _______________________________ Trainer’s Phone during Competition: ____________________________________

HORSE RIDER/HANDLER OWNER (At least one) TRAINER COACH (if applicable) USEF#

USEF#

USEF#

USEF#

USEF#

USDF#

USDF# USDF#

LOCAL ASSN # All USEF members (including riders, handlers, trainers, coaches, owners, agents or lessees) are required to submit proper membership documentation to the show secretary prior to competing. Exhibitors who do not

Unless show provides entry verification service: * MUST attach copies of USEF & USDF Horse Recording and Registration Certificates for GAIG/USDF Qualifying and Championship Classes. * MUST include a copy of USEF Amateur Certification if competing as an Adult Amateur. Go to http://www.eqverification.org/ to print copies.

send a copy of their card with their entry or are unable to produce the card when registering at the competition, or for whom the competition cannot verify such information (with the exception of Federation measurement cards) will be required to pay a $30 non-member fee which is non-refundable. EACH Junior and Senior participant (rider, handler, trainer, coach and one owner/agent per horse) is required to be a USEF Active “Competing” Member or pay a $30 non-member fee (see the official USEF non-member Statement in prize list). Non-U.S. citizen participants in Dressage/DSHB classes MUST attach current proof, in English, of current membership in good standing in their own N.F in order to be exempt from USEF non-member fees.

Class # Day Class Name (Level//Division/Test – if TOC) GAIG Fee Fee Payment For Fee Office Use

Subtotal, Class Fees USEF Non-Member Fee(s)

($30 per participant) USEF Fee per horse:

(D&M $8+ USEF $8) = $16 CDI horses only: USEF Fee per

horse: (D&M $20 + USEF $8) = $28 CDIs only: USEF IHP Discipline Fee

($35 per entry) Stabling / Grounds Fee (For Non-

Stabled Horses) USDF Non-Member Fee(s)

($25 per rider/owner) Office Fee Late Fee, Bridle Number Fee,

Camper Fee SUBTOTAL Class Fees Other Fee(s)

JR or YR Birthdate: _________________________ Riders are eligible to compete as a Jr/YR until the end of the calendar year in which they reach the age of 21 TOTAL FEES DUE:

CDI / CDI-Y/ CDI-J/ CDI-P COMPETITORS MUST COMPLETE THE FOLLOWING INFORMATION:

Rider: Citizenship: FEI Rider Registration #: Competing for Country:

Present Nationality: Birthdate: Previous Name (if any): Horse:

FEI Passport #: FEI Horse Registration #: Person Responsible:

Owner: Citizenship: Owner Social Security or Tax ID # (required to receive prize money):

US Equestrian Federation, Inc. Entry Agreement I have read the United States Equestrian Federation, Inc. (the “Federation”) Entry Agreement (GR906.4) as printed in the Prize List for [insert name here] (“Competition”) and agree to all of its provisions. I understand and agree that by entering this Competition, I am subject to Federation Rules, the Prize List, and local rules of the competition. I agree to waive the right to the use of my photos from the competition, and agree that any actions against the Federation must be brought in New York State. Federation Release, Assumption of Risk, Waiver and Indemnification This document waives important legal rights. Read it carefully before signing. I AGREE in consideration for my participation in this Competition to the following: I AGREE that “the Federation” and “Competition” as used herein includes the Licensee and Competition Management, as well as all of their officials, officers, directors, employees, agents, personnel, volunteers and Federation affiliates. I AGREE that I choose to participate voluntarily in the Competition with my horse, as a rider, driver, handler, vaulter, longeur, lessee, owner, agent, coach, trainer, or as parent or guardian of a junior exhibitor. I am fully aware and acknowledge that horse sports and theCompetition involve inherent dangerous risks of accident, loss, and serious bodily injury including broken bones, head injuries, trauma, pain, suffering, or death. (“Harm”). I AGREE to hold harmless and release the Federation and the Competition from all claims for money damages or otherwise for any Harm to me or my horse and for any Harm of any nature caused by me or my horse to others, even if the Harm arises or results, directly or indirectly, from the negligence of the Federation or the Competition. I AGREE to expressly assume all risks of Harm to me or my horse, including Harm resulting from the negligence of the Federation or the Competition. I AGREE to indemnify (that is, to pay any losses, damages, or costs incurred by) theFederation and the Competition and to hold them harmless with respect to claims for Harm to me or my horse, and for claims made by others for any Harm caused by me or my horse while at the Competition. I have read the Federation Rules about protective equipment, including GR801 and, if applicable, EV114, and I understand that I am entitled to wear protective equipment without penalty, and I acknowledge that the Federation strongly encourages me to do so while WARNING that no protective equipment can guard against all injuries. If I am a parent or guardian of a junior exhibitor, I consent to the child’s participation and AGREE to all of the above provisions and AGREE to assume all of the obligations of this Release on the child’s behalf. I represent that I have the requisite training, coaching and abilities to safely compete in this competition. I AGREE that if I am injured at this competition, the medical personnel treating my injuries may provide information on my injury and treatment to the Federation on the official USEF accident/injury report form. BY SIGNING BELOW, I AGREE to be bound by all applicable Federation Rules and all terms and provisions of this entry blank and all terms and provisions of this Prize List. If I am signing and submitting this Agreement electronically, I acknowledge that my electronic signature shall have the same validity, force and effect as if I affixed my signature by my own hand. BOD 1/23/11 Effective 12/1/11

*RIDER/HANDLER (mandatory) *OWNER / AGENT (mandatory) *TRAINER (mandatory) COACH (If applicable) Signature:

Signature: Signature (must be 18 or older): Signature:

Print:

Print: Print: Print:

PARENT/GUARDIAN (Required if rider/handler is a minor, i.e. under 18) Home Emergency Phone Contact # Is RIDER a U.S. citizen? (mandatory) Signature:

Print:

YES ________ NO ________

* No entry is valid without original signatures from the above individuals; Photocopied signatures or writing “same” are NOT acceptable. STABLING / CAMPER HOOK-UP RESERVATION FORM (Refer to Prize List for Specifications) ENTRY PREPARATION CHECKLIST

Contact NAME and NUMBER for Rider Emergency: Contact NAME and NUMBER for Horse Emergency: Before Mailing, Be Sure You Have:

____________________/______________________ __________________/_______________________ ___Completed Both Sides of Entry Form ___All Original Required Signatures ___________________________________________ _________________________________________ ___ Enclosed a Copy of the Current Name of Lodgings Where Rider or Responsible Party Will be Staying During the Competition

Hotel Number at the Competition (For Emergency Contact Purposes)

Negative Coggins (EIA) Certificate (Refer to Show Specifications for Date Validity

Stall Sex Check Stall Days/Nights Desired (see prize list directives) Requirements. Copy must be legible.)

Occupant (S,M,G) Mon Tues Wed Thurs Fri Sat Sun ___ Supplied all Required Ass’n Numbers Horse Name

___ Enclosed Copies of Applicable USEF and/or USDF Cards or Documents

If accompanied by NON-COMPETING HORSE, must complete separate entry form and pay all applicable fees. ___ Completed the Stabling / Camper Tack

n/a ___ Enclosed a Check / Money Order for

Approx. Time of Arrival:

__________________

Approx. Time of Departure:

__________________

all Applicable Fees. ___Attached photocopy of Test(s) verifying

Special Requests*:

____________________________________________________________________

USDF & FEI Freestyle Test eligibility (ex. for exempt classes)

_______________________________________________________________________________________

Mail this Entry Form, Supplemental Documents, and Fees to the

*Provide name of individual with whom you desire to be stabled (if part of a group, make sure you all name the same person) Competition (Entry) Secretary Identified on the Prize List.

Stabling fees: ___________stalls for ___________nights @ $ _________ per night = __________________

EMERGENCY CELL CONTACT # OF SOMEONE WITH YOU /YOUR GROUP

Camper fees _____hook-ups @ $______ea (flat rate) OR _____nights @ $ _______ per night = _________

AT THIS SHOW WHO IS NOT LISTED ELSEWHERE ON THIS ENTRY FORM

TOTAL STABLING / CAMPER HOOK-UP FEES: _________________

________________________________

PLEASE SUBMIT ANY IMPORTANT INFORMATION FOR THE ANNOUNCER ON A SEPARATE SHEET

Final 9/11

2012 Great American Insurance Group/ USDF Regional Dressage Championships

A single Regional Dressage Championship program organized by the United States Dressage Federation (USDF), and recognized by the United States Equestrian Federation, Inc. (USEF), will be held in each of the nine USDF regions. In addition, Alaska and Hawaii may each hold state championships if an official request from a Group Member Organization (GMO) is received by April 1 of the prior year.

The Regional Championship Program Rules can be found on the USDF website at www.usdf.org. Please refer to the 2012 USDF Member Guide for the comprehensive list of rules and requirements for this program.

Membership/Registration Requirements for Qualifying and Championships Rider: • Must be a USDF Participating* Member (PM) at the time qualifying scores are earned and at the time of the championships. • Must be a USEF member (Junior Active, Senior Active, or Life) at the time the qualifying scores are earned and at the time of the championships. Horse: • Must be USDF Lifetime Registered (LTR) at the time qualifying scores are earned and at the time of the championships. • Must be USEF (Annual or Lifetime) recorded at the time qualifying scores are earned and at the time of the championships. • USDF horse registration and USEF horse/recording must be in the name(s) of the current owner(s) or lessee(s) of record. • A horse is not required to have breed registry papers. Owner: • Must be a USDF member (PM* or Business Member (BM)) at the time the qualifying scores are earned and at the time of the championships. • Must be a USEF member (Junior Active, Senior Active, or Life) at the time qualifying scores are earned and at the time of the championships. * PMs are USDF members who join USDF directly. USDF Group Members (GM) are ineligible.

Final 9/11

Minimum Qualifying Scores One set of nationally-standardized qualifying scores has been established for all USEF/USDF Regional Championships, for levels through Grand Prix, in three divisions: open, adult amateur and junior/young rider. FEI Junior and FEI Young Rider classes have only one respective division. Freestyles have only open divisions. The minimum percentages are as follows: OPEN AA JR/YR Training Level (Test 3) 68% 63% 63% First Level (Test 3) 66% 62% 62% Second Level (Test 3) 64% 61% 61% Third Level (Test 3) 62% 60% 60% Fourth Level (Test 3) 62% 60% 60% FEI Junior (Team Test) — — 60% FEI Young Rider (Team Test) — — 60% Prix St. Georges 60% 60% 60% Intermediate I 60% 60% 60% Intermediate II 60% 60% 60% Grand Prix 60% 60% 60% FREESTYLE OPEN AA JR/YR First Level 63% — — Second Level 63% — — Third Level 63% — — Fourth Level 63% — — Intermediate I 63% — — Grand Prix 63% — —

Competitions/rev. 10/10/2011

2012 USDF/Dover Saddlery Adult Amateur Medal Program The USDF/Dover Saddlery Adult Amateur Medal Program is designed to specifically

recognize and encourage adult amateurs riding at Second Level. Awards 1. USDF/Dover Saddlery Medal Recipient The eligible rider with the highest score of 60 percent or better in the designated Second Level Test Three class or applicable test of choice USDF/Dover Saddlery Adult Amateur Medal class at a participating competition will receive a handcrafted USDF/Dover Saddlery pewter medal and neck ribbon. Winners will receive a $20 Dover Saddlery gift certificate for the first three USDF/Dover Saddlery Medals they win during the competition season.

2. USDF/Dover Saddlery National Merit Award A USDF/Dover Saddlery National Merit Award will be awarded to riders winning three USDF/Dover Saddlery Medals in the same competition year.

3. Year-End Awards The USDF/Dover Saddlery Medal National Champion and Reserve Champion are determined from the average of the top three winning ride scores during the competition year. The champion receives a $1000 Dover Saddlery gift certificate and the reserve champion receives a $500 Dover Saddlery gift certificate.

Rider Eligibility 1. Rider must have a current USDF Participating or Group Membership and be a

member in good standing of USDF when the scores are earned. 2. Rider must be an adult amateur in accordance with Article GR1306 of the USEF

rules and be designated with USEF as an adult amateur at the time the scores are earned.

Owner & Horse Eligibility 1. Horse and owner must meet minimum competition eligibility requirements at the

time scores are earned. Additional Information For additional information and an updated list of competitions offering the USDF/Dover Saddlery Adult Amateur Medal Program, please visit http://www.usdf.org/awards/performance/adultmedalprogram.asp.

The 2012 Colonel Bengt Ljungquist

Memorial Championships Rules

Method:

Horse/rider teams qualify by riding in designated BLM qualifying classes at participating competitions. Qualified horse/rider teams

will then compete at the Finals.

Awards:

Prize money for places 1-3. At Training and First Levels (excluding Musical Freestyles), ribbons for places 1-10. All other levels,

ribbons for places 1-8. Separate Finals classes will be held for Junior/Young riders at the USEF levels (excluding freestyles). If there

are 3 or more Junior/Young riders at any FEI levels (excluding Freestyles), a separate Finals class will be held for the corresponding

level(s).

Qualifying rules:

1. A horse/rider team qualifies as a team, and only the same team may compete at the Finals.

2. The rider must be a member of a participating USDF GMO dressage association at the time of qualification.

3. To be eligible to compete in the Finals in a given level, the horse must not have been shown before Oct. 18, 2012 in any test two

levels above that level in shows licensed by the USEF, the FEI or any other National Federation. Exception: Riders who have

never shown two levels above their Finals level may ride experienced horses.

4. The rider is responsible for submitting a form as proof of qualification to the Championships Secretary as soon as possible after

the qualifying ride. (Qualification Form available on www.CBLM.org and from Bettina Longaker, email address on following

page). Please include your email address. No rider will qualify until the Secretary receives a properly filled-out

qualification form. The Secretary will confirm qualification by a qualification list on the official CBLM website. Only riders

who have NOT qualified will be individually notified.

5. Competitions may not charge extra fees for qualifying rides.

6. ANY class offered that is a CBLM test will be designated as a qualifying class.

7. Only those competitions listed will be used as qualifying competitions. Over a period of four days or less, no more than two

qualifying competitions may be held at the same location.

8. Winning horse/rider teams at the Finals will be ineligible to compete at the same level in succeeding years, except for Intermediate

II, Grand Prix, Grand Prix Freestyle, and Pas de Deux.

9. The 2012 Finals classes may be used to qualify for 2013 and the MFS and FEI Finals may be used to qualify for the USDF/GAIG

Finals in 2013.

10. The last date to qualify for the 2012 Finals is September 23, 2012.

Qualification Requirements: USEF levels: 1. The horse/rider team must achieve the following minimum percentages (qualifying tests to be used are indicated):

Training Level Test 2 65% (Seniors) 63% (Juniors/YR)

First Level Test 2 62% (Seniors) 60% (Juniors/YR)

Second Level Test 2* 62% (Seniors) 60% (Juniors/YR)

Third Level Test 2** 62% (Seniors) 60% (Juniors/YR)

Fourth Level Test 2 62% (Seniors) 60% (Juniors/YR)

2. FEI levels: A horse/rider team must achieve the following minimum score in any FEI class at a qualifying show (National and

CDI); FEI TOC classes may be used.

Prix St. Georges*** 60% (Seniors) 58% (Juniors/YR)

Intermediate I 60% 58% (Juniors/YR)

Intermediate II 60%

Grand Prix 60%

Musical Freestyles: The Qualifying score is 63%. At the Finals, there will be six freestyles. 1) First Level; 2) Second Level*; 3)

Third Level**; 4) Fourth Level****; 5) Intermediate I; 6) Grand Prix. Any type of freestyle class will be accepted, including

GAIG/USDF qualifying classes, USDF or FEI musical freestyles, or CDI freestyles.

Pas de Deux: The Qualifying score is 65%. This level will be discontinued in 2013 if more pairs do not qualify & compete in the

2012 Finals competition.

* - FEI Pony Test may be ridden by Juniors to qualify at 2nd

level; they will ride 2nd

Level Test 2 in the Finals & 2nd

MFS

** - FEI Junior Tests may be ridden by Juniors to qualify at 3rd

level; they will ride 3rd

Level Test 2 in the Finals & 3rd

MFS

*** - FEI Young Rider Team tests may be ridden by eligible Young riders respectively to qualify at PSG; they will ride PSG in the

Finals

**** - FEI Young Rider Freestyle may be ridden by eligible Young Riders to qualify for 4th

Level MFS; they will ride 4th

MFS in the

Finals

(Age is determined by the age of the rider as of December 1: Junior = 18 & under; Young Rider = 16 – 21 yr.)

Rules Governing the Finals

1. The same tests used to qualify will be used in the Finals, except the FEI Pony, Junior & Young Rider tests listed above.

2. The tests must be ridden from memory and without whips.

3. No horse/rider team may ride Hors de Concours in a Finals class.

4. Entries for the Finals classes must be sent on the current Official Entry Blank to the current year’s Finals Entry Secretary,

Bettina Longaker.

5. A horse/rider team may qualify at more than one level and all qualified horse/rider teams are permitted to compete in the

Finals in consecutive qualified levels; this includes the corresponding Musical Freestyle finals.

6. Only ONE horse/rider combination may show in the Finals. If two riders qualify the same horse at different levels, the choice

must be made and only one Finals horse/rider combination will be accepted by the Finals Show Secretary.

7. During the Finals competition, no horse entered in a Ljungquist Final may be ridden by anyone other than the rider entered in

the Final on that horse until that combination has finished their Finals class(es); this includes the awards ceremony. (At this

point, the horse/rider combination may compete in open classes with new entry form and bridle number.)

8. Training Level and the First Level Finals for senior riders will consist of two divisions: a) riders who have not competed at

or above Third Level at an USEF licensed show, and b) riders who have competed at or above Third Level at an USEF

licensed show.

9. Second through Third Levels for senior riders will consist of two divisions: a) riders who have not competed at or above the

FEI Prix St. Georges level or in any of the FEI Young Rider levels at an USEF licensed show, and b) riders who have

competed at or above the FEI Prix St. Georges level or in any of the FEI Young Rider levels at an USEF licensed show.

10. Fourth Level for senior riders will consist of two divisions: a) riders who have not competed at or above the FEI

Intermediaire I at an USEF licensed show, and b) riders who have competed at or above the FEI Intermediaire I at an USEF

licensed show.

11. Prix St Georges for senior riders will consist of two divisions: a) riders who have not competed at or above the FEI

Intermediaire II at an USEF licensed show, and b) riders who have competed at or above the FEI Intermediaire II at an USEF

licensed show.

12. The Championship competition is to be held within USDF Region 1 only.

CBLM Website: http://www.cblm.org

To get a qualification form, check the website or send a self-addressed, stamped envelope to:

Bettina Longaker, Championship Qualifying Secretary

vadvirag8@gmail.com

8246 Open Gate Rd Gordonsville, VA 22942

30th Annual Col. Bengt Ljungquist Memorial Championship Finals

Presented by Trilogy Saddlery

Virginia Horse Center

October 18 - 21, 2012

Qualifying & Finals Show Secretary

Bettina Longaker

(vadvirag8@gmail.com, 540-832-7611)

8246 Open Gate Rd Gordonsville VA 22942

Participating USDF Group Member Organizations

Carl Asmis Memorial DA, Commonwealth DCTA, Connecticut DA, Delaware Valley CTA, East Coast Regional DA, Eastern States

DCTA, French Creek DA, Garden State DS, International Equestrian Org., Lehigh Valley DA, Maryland DA, North Carolina DCTA,

Orange County DA, Oley Valley CTA, Potomac Valley DA, South Carolina DCTA, Virginia DA, Western Pennsylvania DA