Belle Starr Shootout Breakaway and Tie Down Entry Form

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Please Print Clearly

Name___________________________________________________________________________

2Address_________________________________________________________________________

City, State, Zip Code______________________________________________________________

Email address____________________________________________________________________

Birthday_____________________________ Age_______Phone___________________________

Jacket and shirt size Men’s Size ____________ Ladies Size________________ Membership
Number
MEMBERSHIP TYPE pick one (required)
__________
*Basic Membership $15 _________ _
*Pearl’s Helper Membership $100 _________
Includes a 5 Star Mohair Cinch Please circle size 26 28 30 32 34 36
* Belle’s Sponsorship Membership Package $250 _________ Special Breakaway Prizes for
Includes a 5 Star Pad Please circle thickness 1 1/8” 1” 7/8” and size 32”x32” 30”x30” under 18 and over 40 day of
o Ladies Breakaway Roping $350 __________ roping. Check if you qualify
____ Under 18 ____ Over 40
o Tie Down $150 __________
o Wrangler Tie Down Sidepot (WPRA Only) $50 __________ Balance due day of roping.
Must send $100 Deposit per event Post marked by 4-19-18 __________ No refunds. Must be
Breakaway and/or Tie-Down Late Fee day of roping only $30 __________ postmarked by April 19,
otherwise pay at roping.
Total ___________ Team roping entries onsite
____________________ only.
MEMBER NAME _____________________________________________________ DATE ___________________ (PRINT)
MEMBER RELEASE FORM COWGIRL RICHES LLC MEMBERSHIP/CONTESTANT RELEASE– By making application for membership and/or making
entry as a participant, I understand that no matter how careful the sponsors, officers, directors, agent, contractors or participants may be, my
injury or death, as well as my that of my property, animals, agents or family is a possibility. I hereby release the owners or lessors of the
premises, arena or facilities hosting or used to conduct and/or host the Cowgirl Riches LLC events, and any sanctioning body of the said event,
the undersigned, on his or her own behalf, and on behalf of his or her immediate family members and all of their agents, personal
representatives, next of kin, heirs, estate, successors and assigns, or any other person or entity affiliated therewith (the “Releasing Parties”),
does hereby expressly and knowingly assume all risk of injury from the Events and does hereby expressly agree to forever discharge, release,
defend, indemnify and hold harmless Cowgirl Riches, LLC, Host Qualifying Event and Sanctioning Body or any of their present and future
officers, directors, partners, employees, shareholders, stakeholders, agents, representatives, corporate affiliates, successors and assigns and
other participants (all of which are collectively referred to herein as the “Releasees”) from and against all losses, liability, obligations, damages,
costs, demands, suits, judgments or expenses whatsoever (including reasonable attorneys’ fees and court costs), whether known or unknown,
accrued or contingent, that the undersigned may have, or contend to have, on account of injury, including permanent disability, death, or
damage to property, caused by or alleged to be caused, in whole or in part, as a result of participation in the Events, including all claims arising
out of the negligence of the Releasees. I also acknowledge Cowgirl Riches LLC events may be filmed or photographed (using various forms of
media) and by entering said events I am releasing use of such media to Cowgirl Riches LLC for publication and promotions and grant Cowgirl
Riches LLC the unrestricted right to use and edit this information as needed. I further certify that I have available upon the request of event
management; a current health certificate and COGGINS test for each animal present per state regulations. If authorities require presentation of
said documents, I will personally be responsible for any fines levied on the event producer if I am unable to present such documents. I
understand my name, address and email will be added to the Cowgirl Riches LLC mailing list. If I wish to opt out, I may note such choice on this
form or may opt out on any communication.

DATE _________________ SIGNATURE____________________________________________ Under 18 ? _ (If under 18 must be signed also by

parent/legal guardian)
DATE _________________ SIGNATURE____________________________________________ (Parent/Legal Guardian)
MAIL WITH PAYMENT TO - COWGIRL RICHES LLC, 7114 Dean Road, Alma, AR 72921 479 650-6931