2016 WAYNE COUNTY 4-H Horse Forms Packet · reverse side. In consideration for the opportunity to participate in club, county, district and state 4-H horse activities and the use

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

2016 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 2nd. 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 2nd. 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




wayne.osu.edu

2016 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:




wayne.osu.edu

2016 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:




wayne.osu.edu

2016 WAYNE COUNTY 4-H Horse Project Guidelines / By-Laws

Receipt Form

PleasereturncompletedformstotheWayneCountyExtensionOfficeby4:30pmonJune1st–noexceptions!

Ihavereceived,read,understand,andagreetoabidebyalloftherules,deadlines,andotherinformationcontainedinthe2016WayneCounty4-HHorseProjectGuidelinesandBy-LawsPacket.Member’sSignature_______________________________________Date_____________________________________Member’sName(print)____________________________________Club______________________________________Parent/Guardian’sSignature_______________________________Date_____________________________________




wayne.osu.edu

2016 WAYNE COUNTY 4-H P.A.S. Show Entry Form

PleasereturncompletedformstotheWayneCountyExtensionOfficeby4:30pmonJune1st–noexceptions!

Name__________________________________Club___________________________AgeDivision_____Jr._____Sr.Address_______________________________________________City____________________State____Zip_________Phone_______________________________E-Mail:________________________________________________________AgeasofJanuary1_____DateofBirth_________Yearsin4-H______Parent/GuardianName(s):___________________

Note:Youmayonlytrytoqualifywithoneanimal,whichyoumustchooseatthistime.Horse__________Pony__________HorseorPonyName:___________________________________________________Selectnomorethan4classes(includinggroundroping).GroundropersmustqualifyinatleastoneotherclasstocompeteatStateFair. ToqualifyforStateFairamembermustqualifyinany2classes(groundropingplusoneotherclass).Memberscanqualifyandshowin3classesatStateFair,plusgroundroping,foratotalof4.

____ 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

*TheexhibitorcannotshowthesamehorseinRanchPleasureandWesternPleasureatthesameshow.

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.




wayne.osu.edu

2016 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 2, 2016. 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




wayne.osu.edu

2016 Wayne County Jr. Fair Horse Youth of the Year

Award Application

Must be turned in at the Extension Office by 4:30 pm on Monday August 1, 2016

Any 4-H or FFA horse youth may apply for this award. One award will be presented to a junior and one award presented to a senior during Fun Show Awards to be presented during the Wayne County Fair. Criteria for the award will include: written application (65%), Fun Show Points (15%), and 4-H Advisor or FFA Advisor recommendation letter (20%). Juniors are youth 13 and younger as of January 1st and Seniors are youth 14 and older as of January 1st. Name:___________________________ Age (as of Jan. 1) ________ Circle One: Junior Senior Address:_________________________________________________________________________ City:______________________________________________ State:______ Zip:________________ Phone:_________________________ E-Mail:____________________________________________ Parent / Guardian’s Name(s):_________________________________________________________ 4-H Club or FFA Chapter:____________________________________________________________ Youth Signature_________________________________________________ Date:______________ Advisor’s Signature______________________________________________ Date:______________

2016 Wayne County Jr. Fair Horse Youth of the Year Award Application (You may attach additional pages if you would like to) Number of years you have been involved with horses:_________________ 1) Please list and/or describe the horse related activities you have participated in and number of years for each activity? 2) Please list and/or describe any non-horse related activities you have participated in and the number of years? 3) What leadership roles are you currently in?

4) Please provide your definition of sportsmanship? 5) What do you do in your 4-H club or FFA chapter to help the other members in your club? 6) Why do you feel you deserve the Horse Youth of the Year Award?

2016 WAYNE COUNTY 4-H Horse Forms Packet · reverse side. In consideration for the opportunity to participate in club, county, district and state 4-H horse activities and the use

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