2010 Vermont Endurance Rides

Vermont 100/Moonlight 50/75

July 17, 2010
West Windsor, VT

Rider AERC # (enter N/A if no number) ECTRA #

First Name Last Name

Weight Division Please Select A Division Feather (160/below) Light (161-185) Middle (186-210) Heavy (211/up) Sponsored Junior For junior rider's between 12 and 16 years of age: Date of Birth

Jr. Sponsor's Name Junior Riding As adult?

Jr. Sponsor's Address

Rider's Address

City State ZIP Phone Email

Emergency Contact (At home) Contact Phone Number

Entry Information:

Please Select the ride you plan to enter: This is my first Endurance Ride   This is my first 100 Mile Endurance Ride

Ride: Click to Select Vermont 100 AERC Moonlight 75 AERC Moonlight 50 AERC

Horse AERC# ECTRA Horse #

Horse Name Horse Age Gender Click to Select Gelding Mare Stallion

Color Markings Breed

Owner AERC # (if different than rider) Owner Name

Fees:

Entry,  Includes ALL Rider Meals & Drug Fees Choose Ride Vermont 100 AERC ($175.00) Vermont 100/JR ($90.00) Moonlight 75 ($145.00) Moonlight 75/JR ($70.00) Moonlight 50 ($125.00) Moonlight 50/JR ($60.00)

AERC Non-Member Fee ($15.00) No # list above, Fee must be included if AERC # not given. Non-Member N/A $15.00

(After 7/12/2010) Late Fee NA $35.00

Extra Friday Pasta Dinner @ $16.00 # Extra Tickets Total Amount

Extra Sunday Awards Brunch @ $16.00 # Extra Tickets Total Amount

Total Amount Enclosed

Please make checks for the full amount, payable to Vermont Adaptive Ski and Sport and send to:

Jo Steele
147 Dorchester Rd
Lyme, NH 03768

jo.steele@valley.net
603 795-4666

Please Print and then press Submit below