QHEAC Online Entry – Horse Show Secretary

Name of Horse (required)

Year Foaled (required)

Sex (required)
MareStallionGelding

Registry Number (required)

Registry (required)

Is this horse leased? (required)
YesNo

Owner Name (required)

AQHA Number (required)

AQHA Expiration Date (required)

Owner Mailing Street Address (required)

Owner City, State & Zip (required)

Owner Phone Number (required)

Owner Email (required)

Owner/Exhibitor Same? (required)
YesNo

Will this horse be stalled? (DEADLINE 9-22-2022 - Stalls/Tack Stalls * Two or more nights (before deadline $175/after deadline $195) * One night/day (before deadline $125/after deadline $195) * Early arrival or late departure ($25/night)) (required)
YesNo

Stalled with?

Arrival Date

Departure Date

Reserve tack stall - number of tack stalls needed?

RV Reservation? (DEADLINE 9-22-2022 *$50/day or night) (required)
YesNo

RV Arrival Date

RV Departure Date

Exhibitor #1 Name (required)

Exhibitor #1 Type (required)

Exhibitor #1 Birthdate (required)

Exhibitor #1 Relationship to Owner (required)

Exhibitor #1 ID Number (required)

Exhibitor #1 ID Type (required)

Exhibitor #1 Expiration Date (required)

Exhibitor #1 Street Address (required)

Exhibitor #1 City, State & Zip (required)

Exhibitor #1 Phone (required)

Exhibitor #1 Class Entry (required)

Exhibitor #2 Name

Exhibitor #2 Type

Exhibitor #2 Birthdate

Exhibitor #2 Relationship to Owner

Exhibitor #2 ID Number

Exhibitor #2 ID Type

Exhibitor #2 Expiration Date

Exhibitor #2 Street Address

Exhibitor #2 City, State & Zip

Exhibitor #2 Phone

Exhibitor #2 Class Entry

PAYMENT INFORMATION - Please enter name on credit card

Credit Card Number

Credit Card Expiration Date

CVV

Zip Code

WAIVER RELEASE: As a condition of my participation and/or the participation of my child in this event, I agree as follows: I release QHEAC, the Rolling Hills Casino, its employees, volunteers, agents, the show facility, and the management of this show from any loss, damage or illness that may occur to me, my horse, or my property as a result of my and/or my horse(s) attendance at or participation in this event. I am responsible for any loss or damage caused by me or my agents at this show grounds and I will pay any bill rendered to me for such loss or damage. My signature also authorizes payment of all show fees with credit card as listed on this entry form.

PLEASE PRINT NAME. (OWNER/AGENT/RESPONSIBLE PARTY) (required)

[date today's-date placeholder "Today's Date (required)"]

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