Open Entry Form

Rider

First Name Last Name

Rider Date of Birth

Date

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Area Code Phone Number

Open 5D has 1/2 second splits. Age Incentives are 3D with 1 second splits.

Age Incentives are 0-18, 19-49, 50-? based on rider's age on 3/13/2021.

Future Fortunes Regional Championship is for Saturday Open with no additional fee. MUST SUBMIT ENTRY FORM AND REGISTRATION PAPERS BEFORE 3/13/2021.

Horse 1 Registered Name

Future Fortunes

Yes-must submit required entry form with registration papers No

Horse 1 Entries

Friday Jackpot - $25 Saturday Open - $65 Saturday Age Incentive carry-over - $30 SWBRA Sat Co-Sanction - $5 Sunday Open - $65 Sunday Age Incentive carry-over - $30 SWBRA Sun Co-Sanction - $5

Horse 1 Total

Horse 2 Registered Name

Future Fortunes

Yes-must submit required entry form with registration papers No

Horse 2 Entries

Friday Jackpot - $25 Saturday Open - $65 Saturday Age Incentive carry-over - $30 SWBRA Sat Co-Sanction - $5 Sunday Open - $65 Sunday Age Incentive carry-over - $30 SWBRA Sun Co-Sanction - $5

Horse 2 Total

Horse 3 Registered Name

Future Fortunes

Yes-must submit required entry form with registration papers No

Horse 3 Entries

Friday Jackpot - $25 Saturday Open - $65 Saturday Age Incentive carry-over - $30 SWBRA Sat Co-Sanction - $5 Sunday Open - $65 Sunday Age Incentive carry-over - $30 SWBRA Sun Co-Sanction - $5

Horse 3 Total

Horse 4 Registered Name

Future Fortunes

Yes-must submit required entry form with registration papers No

Horse 4 Entries

Friday Jackpot - $25 Saturday Open - $65 Saturday Age Incentive carry-over - $30 SWBRA Sat Co-Sanction - $5 Sunday Open - $65 Sunday Age Incentive carry-over - $30 SWBRA Sun Co-Sanction - $5

Horse 4 Total

Prepaid Time Onlys

Each one - $5

Quantity

Time Only Total

See time only schedule on website for availability and ENTER REQUEST HERE.

Time slots each half hour

Additional Items *

Processing Fee - $10

Additional Items *

Late fee after March 3 - $10

Signature of Participant or Legal Guardian

Clear

Total owed

Payments can be submitted by Venmo @dixieclassic or mail a check to

Dixie Classic at 394 S Main Street, Washington, UT 84780.

Entry is complete when your payment is received.

Dixie Classic - Open Entry Form