Event Derby Registration Form
Join us on Saturday, July 1, 2017 at Herron Park!
Please complete this form, print and sign the required Liability Release (https://goo.gl/O00Oyr), and send your payment (checks made out to FCTA) to show secretary:

Sally Rohletter
1458 14th Street EN
Columbia Falls, MT 59912

Payment should be postmarked or delivered by Tuesday, June 27 to avoid $15 late fee. You will need to complete one form for each horse. Make sure you click "submit" when you finish filling out the form. All proceeds from this event go to maintaining the jumps and dressage arenas at the park.

*USEF rules will apply as guidelines for all FCTA events. ALL riders while mounted must wear ASTM/SEI approved helmet. BodyProtector vests are strongly encouraged. Every participant must sign release form or have parent/guardian sign if they are less than 18 years old.

Please contact Sally Rohletter (srohletter06@gmail.com or 406-249-7852) if you have any questions.

Rider's Name
Your answer
Rider's Mailing Address
Your answer
Rider's Phone Number
Your answer
Rider's Email
Your answer
Rider's Age
Your answer
Parent/Guardian's Name
Enter N/A if rider is an adult.
Your answer
Horse's Name
Your answer
Horse Owner's Name and Phone Number
Your answer
Level Competing
$45/mini event division
Individual/Additional Dressage Tests
$20/test for dressage tests only.
Additional Jumping Rounds
$15/any level, just indicate the number of additional rounds requested (Must be entered in derby to add additional rounds.)
Are you a current FCTA member?
$15 non-member fee or $25/individual to join or $40/family
Stall needed
$25/stall/night payable to Flathead County Parks & Recreation
Camp site needed
$10/night/site payable to Flathead County Parks & Recreation
Total Amount of Payment Sent
If you are planning on camping and/or using a stall, please send a separate check made payable to Flathead County Parks and Recreation. Payment needs to be postmarked by Tuesday, June 27 to avoid the $15 late fee. *Remember to add your division ($45), additional dressage/jumping rounds, non-member fee (or new membership), and stabling/camping (separate check).
Your answer
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