2015 wayne county 4-h horse forms packet · reverse side. in consideration for the opportunity to...
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OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
_______________________________
Member’s Name
______________________________ Club
2015 WAYNE COUNTY 4-H
Horse Forms Packet
This packet contains important Horse forms that are due June 1st. It also includes the Special Request form that is due May 15th. Please be sure to read the Horse Project Guidelines / By-Laws Packet and then complete the forms in this packet. Please return this packet completed and in tact without removing the staple in the upper left corner to the Extension Office. If you are submitting the special request form, it is permissible to go ahead and remove that form since it is due on May 15th. If you need to add more Horse ID forms or more PAS Show Entry forms, it is acceptable to copy the forms and add them in. However, please turn in a completed packet with the forms in the same order as they are in this original packet and all stapled together! Please note: There are 2 copies of the Horse Photo Id and Horse Id (drawing / sketch) forms included in this packet since youth are permitted to show two equine animals. You may id more than 2 animals if you are not yet sure which animals you will be showing. If you have any questions in completing these forms, please contact your advisor or the Extension Office.
PERMISSION TO PARTICIPATE IN 4-H HORSE ACTIVITIES
DISCLOSURE AND RELEASE OF CLAIMS
I, _________________________________________, have
chosen to participate in the Ohio 4-H Horse Program and its
related horse activities. I understand that this participation
will involve contact with horses and may give rise to a risk of
physical injury.
I am aware that:
A. Horses have a tendency to behave in ways which
may result in injury, death, or loss to riders, or other
persons in the immediate vicinity;
B. Horses may react in an unpredictable way to sounds,
sudden movement, unfamiliar objects, persons, or
other animals;
C. Riding a horse may give rise to a risk of injury from
hazards arising from the surface or subsurface of
the ground in which these riding activities occur;
D. While in the vicinity of a horse or while riding a horse,
I may be involved in a collision with another
horse, another animal, a person, or an object;
E. Other participants in the program may fail to maintain
control over a horse or fail to act within their
abilities, thus causing harm to me or other
participants; and
F. Other participants in the program may act in a
negligent manner, which could result in harm to me.
As parent or guardian I have discussed with my child the need
to behave in a safe manner. I will make sure that my child
wears appropriate clothing and footwear during horse
activities. I further agree that my child shall be subject to the
helmet policy which is reprinted for convenience on the
reverse side.
In consideration for the opportunity to participate in club,
county, district and state 4-H horse activities and the use of
services and facilities made available through these 4-H horse
activities, I do release and forever discharge for myself and
my heirs, executors, administrators, and assigns, the Ohio 4-H
Horse Program professional and volunteer leaders, agents, The
Ohio State University and its Board of Trustees, its
administrators, faculty and staff, from all claims, demands,
and causes of action for personal injury or any other damage
which may arise out of or be in any way related to my
participation in this activity or program.
I understand that my child is not required to participate in any
horse activity, but grant permission for him/her to do so,
despite the possible risks. I recognize that by participating in
these activities, as with any physical activity, my child may
risk personal injury. I hereby attest and verify that I have been
advised of the potential risks, that I have full knowledge of the
risks involved in these activities, and that I assume any
expense that may be incurred in the event of an accident,
illness, or other incapacity, regardless of whether I have
authorized such expenses. As a parent/guardian, I assume the
same risk for myself, and other family members and friends
present at these horse activities.
Signed: ______________________________________
(4-H Member)
Date _______________
Signed:_______________________________________
(Parent or Guardian)
Date _______________
This form needs to be signed and on file for each youth
participant in any 4-H horse program activity. The form needs
to be signed each year and before a youth participates in the
Ohio 4-H Horse Program Activities.
Under Ohio law, Section 2305.321 of the Revised Code, an
equine activity sponsor, professional, volunteer, participant or
other person is not liable for an injury to or the death of a
participant in the equine activities resulting from the inherent
risks of equine activities.
4-H Equine Mandatory Helmet Use Policy
All youth 19 years and under, participating in any 4-H
equestrian activity, are required to wear properly fitted
protective headgear which meets or exceeds current ASTM
(American Society for Testing and Materials)/SEI (Safety
Equipment Institute) standards with the chin harness securely
fastened at all times while riding or driving an equine.
It is the responsibility of the rider, or the parent or guardian of
the youth participant, to make sure that the headgear worn
complies with appropriate safety standards for protective
headgear intended for equestrian use, and is properly fitted
and in good condition. The Ohio 4-H Horse Program, Show
Committees, Officials, Extension Personnel and Volunteer
Leaders are not responsible for checking headgear worn for
such compliance.
The Ohio 4-H Horse Program, Show Committees, Officials,
Extension Personnel and Volunteer Leaders make no
representation or warranty, expressed or implied, about any
protective headgear, and cautions riders that death or serious
injury may result despite wearing such headgear, as no helmet
can protect against all foreseeable injuries in equestrian
activities.
The Ohio 4-H Horse Program, Show Committees, Officials,
Judges, Extension Personnel and Volunteer Leaders may, at
his/her discretion, check a participant’s protective headgear
for proper standards. If the youth is found to be wearing
unapproved, defective, or improperly fitted headgear, he/she
will not be permitted to participate in riding or driving
activities until proper headgear is acquired.
Return to your local
OSU Extension, Ohio 4-H Program Office
By: June 1st
White Copy – Extension Office Yellow Copy – Club Advisor
OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
2015 WAYNE COUNTY 4-H Horse Photo Identification Form
(Due to the Extension Office June 1st) 4-H Member’s Name__________________________________________________________ 4-H Club____________________________ Horse’s Name____________________________ Please attach a 4x6 color photo of the left side view of your horse in the space below:
Please attach a 4x6 color photo of the front (head view) of your horse in the space provided on the back of this form.
Please attach a 4x6 color photo of the front head view of your horse in the space below:
OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
2015 WAYNE COUNTY 4-H Horse Photo Identification Form
(Due to the Extension Office June 1st) 4-H Member’s Name__________________________________________________________ 4-H Club____________________________ Horse’s Name____________________________ Please attach a 4x6 color photo of the left side view of your horse in the space below:
Please attach a 4x6 color photo of the front (head view) of your horse in the space provided on the back of this form.
Please attach a 4x6 color photo of the front head view of your horse in the space below:
OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
2015 WAYNE COUNTY 4-H Horse Project Guidelines / By-Laws
Receipt Form
Please return completed forms to the Wayne County Extension Office by 4:30 pm on June 1st – no exceptions!
I have received, read, understand, and agree to abide by all of the rules, deadlines, and other information contained in the 2015 Wayne County 4-‐H Horse Project Guidelines and By-‐Laws Packet. Member’s Signature_______________________________________ Date_____________________________________ Member’s Name (print)____________________________________ Club______________________________________ Parent / Guardian’s Signature_______________________________ Date_____________________________________
OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
2015 WAYNE COUNTY 4-H P.A.S. Show Entry Form
Please return completed forms to the Wayne County Extension Office by 4:30 pm on June 1st – no exceptions!
Name__________________________________Club___________________________ Age Division _____Jr. _____ Sr. Address_______________________________________________ City____________________ State____ Zip_________ Phone_______________________________ E-‐Mail:________________________________________________________ Age as of January 1_____ Date of Birth_________ Years in 4-‐H______ Parent/Guardian Name(s):___________________
Note: You may only try to qualify with one animal, which you must choose at this time. Horse__________ Pony__________ Horse or Pony Name:___________________________________________________ Select no more than 4 classes (including ground roping). Ground ropers must qualify in at least one other class to compete at State Fair. To qualify for State Fair a member must qualify in any 2 classes (ground roping plus one other class). Members can qualify and show in 3 classes at State Fair, plus ground roping, for a total of 4.
____ 1. Sr. Western Showmanship ____ 24. Jr. Working Hunter Over Fences ____ 2. Jr. Western Showmanship ____ 25. Sr. Western Horsemanship ____ 3. Sr. Hunter Showmanship ____ 26. Jr. Western Horsemanship ____ 4. Jr. Hunter Showmanship ____ 27. Sr. Western Pleasure* ____ 5. Sr. Saddle Type Showmanship ____ 28. Jr. Western Pleasure* ____ 6. Jr. Saddle Type Showmanship ____ 29. Sr. Ranch Pleasure* ____ 7. Sr. Draft Showmanship ____ 30. Jr. Ranch Pleasure* ____ 8. Jr. Draft Showmanship ____ 31. Sr. Trail ____ 9. Sr. Hunt Seat Equitation ____ 32. Jr. Trail ____ 10. Jr. Hunt Seat Equitation ____ 33. Driving Reinsmanship Light or Draft (all Ages) ____ 11. Sr. Saddle Seat Equitation ____ 34. Ground Roping ____ 12. Jr. Saddle Seat Equitation ____ 35. Sr. Western Riding ____ 13. Sr. Hunter Under Saddle ____ 36. Jr. Western Riding ____ 14. Jr. Hunter Under Saddle ____ 37. Sr. & Jr. Reining- Pattern C ____ 15. Sr. English Pleasure-Saddle Type ____ 38. Light Horse Driving (all ages) ____ 16. Jr. English Pleasure- Saddle Type ____ 39. Light Pony Driving (all ages) ____ 17. Easy Gaited Pleasure (no trot-all ages) ____ 40. Draft Horse Driving (all ages) ____ 18. Easy Gaited Equitation (all ages) ____ 41. Draft Pony Driving (all ages) ____ 42. Pony or Jr. Poles 15 Minute Break ____ 43. Sr. Poles ____ 44. Pony or Jr. Stakes Race ____ 19. Sr. Hunter Hack ____ 45. Sr. Stakes Race ____ 20. Jr. Hunter Hack ____ 46. Pony or Jr. Keyhole Race ____ 21. Sr. Hunt Seat Equitation Over Fences ____ 47. Sr. Keyhole Race ____ 22. Jr. Hunt Seat Equitation Over Fences ____ 48. Pony or Jr. Barrels ____ 23. Sr. Working Hunter Over Fences ____ 49. Sr. Barrels
* The exhibitor cannot show the same horse in Ranch Pleasure and Western Pleasure at the same show.
PAS FORM FOR YOUTH GOING TO OTHER COUNTIES TO QUALIFY
Youth's Name ___________________________________ Home County _____________________________ Birth Date __________ Age (as of Jan 1st) _______ Home Phone _____________ Cell Phone ____________ Address ___________________________________________________________________________________ Project Horse's Name________________________________ (Animal ID Form MUST be attached) Home County 4H Educator ___________________________ ____________________________________ Printed Name Signature of 4H Educator County where going to qualify for State Fair _________________________________
Class Name
Score Received
Qualified Yes No
1.
2.
3.
4.
Ground Roping
____________________________________________ ____________________________________________ Printed Name Signature of Show Manager/ 4H Educator of county of show of Show Manager/ 4H Educator of county of show Address ___________________________________________________________________________________ Phone ______________________________________ Attention: The Youth going to the other county is responsible to get the information listed above and to return this completed form to the home 4H Educator in time so that they can get the youth entered in the State Fair Junior Fair Horse Show The home 4H Educator must sign this form, list the county the youth is going to and then give it to the youth to take to the show that they are going to, to try to qualify. A youth may not go to more than two shows or one show with two judges.
OHIO STATE UNIVERSITY EXTENSION
CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For
more information: go.osu.edu/cfaesdiversity.
wayne.osu.edu
2015 WAYNE COUNTY 4-H Horse Special Request Form
All special requests for exceptions to the Wayne County 4-H Horse Committee By-Laws and/or other special accommodations for horse youth will be for one project year only and must be presented in writing via this form to the 4-H Horse Committee. Special Request forms should be turned in to the Wayne County Extension Office by 4:30 pm on May 15, 2015. 4-H Member’s Name:___________________________________________________________ 4-H Member’s Club:____________________________________________________________ 4-H Member’s Age as of January 1st of the current year:________________________________ 4-H Member’s Address:_________________________________________________________ ____________________________________________________________________________ Parent / Guardian’s Name(s)_____________________________________________________ Phone:___________________________________ E-Mail:_____________________________ List the 4-H member’s horse’s name(s) below (please list all horse name(s) registered to the member for this year. 1._______________________________ 2._____________________________________ Please describe what your special request is below (attach additional page if necessary): ________________________ ____________________ ____________________________ 4-H Member’s Signature Parent’s Signature Advisor’s Signature
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