Back To Berrien Entry Form

Back To Berrien

AQHA Special Event & NSBA Futurity Entry Form

June 22-25, 2022

Berrien County Fairgrounds

Berrien Springs, MI

PRE-ENTRY DEADLINE: June 1, 2022

Futurity Entries will be accepted after deadline of June 1, 2022

until 5:00 p.m. the day before the class shows and will incur a $100 late fee per class!
Date

Month Day Year
Date
HORSE INFORMATION
Horse Name *
AQHA Registration # *
Year Foaled *
Sex *
NSBA COE # *
(If you are showing in the NSBA portion of the class, you must have a Certificate of Eligibility (Registration Number) with NSBA to enter. You will be able to purchase this at the show as well.)
Sire *
Dam *
Trainer Name:
OWNER INFORMATION
Owner Name: *
(For Leased horses, enter Lessee as Owner Name)
Owner AQHA Number:
AQHA Exp. Date:
MM/DD/YYYY
Owner NSBA Card:
(Enter only if showing NSBA Classes)
NSBA Exp. Date:
MM/DD/YYYY
NSBA Membership Type:
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email *
example@example.com
Phone Number *
EXHIBITOR #1 INFORMATION
Is Exhibitor #1 the same as the Owner:

Yes No
Exhibitor #1 Name *
Date of Birth:
MM/DD/YYYY
Relationship to Owner:
Yth. & Amt. must have valid relationship / Open=None
AQHA #:
AQHA Exp. Date:
MM/DD/YYYY
AQHA Membership Type:
NSBA #:
(If applicable)
NSBA Exp. Date:
MM/DD/YYYY
NSBA Membership Type:
Address if different from Owner

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
Phone Number
Please check boxes for the AQHA SE classes you wish to enter for Exhibitor #1:
AQHA Special Event / NSBA Dual Approved:

301. AQHA Level 1 Hunter Under Saddle 501. NSBA Level 1 Hunter Under Saddle 302. AQHA Youth Hunter Under Saddle 502. NSBA Youth Hunter Under Saddle 303. AQHA Select Hunter Under Saddle 503. NSBA Select Hunter Under Saddle 304. AQHA Amateur Hunter Under Saddle 504. NSBA Amateur Hunter Under Saddle 305. AQHA Junior Hunter Under Saddle 505. NSBA Junior Hunter Under Saddle 306. AQHA Senior Hunter Under Saddle 506. NSBA Senior Hunter Under Saddle 307. AQHA Youth Western Pleasure 13 & Und. 507. NSBA Youth Western Pleasure 13 & Und. 308. AQHA Level 1 Western Pleasure 508. NSBA Level 1 Western Pleasure 309. AQHA Youth Western Pleasure 14-18 509. NSBA Youth Western Pleasure 14-18 310. AQHA Junior Western Pleasure 510. NSBA Junior Western Pleasure 311. AQHA Select Western Pleasure 511. NSBA Select Amateur Western Pleasure 312. AQHA Amateur Western Pleasure 512. NSBA Amateur Western Pleasure 313. AQHA Senior Western Pleasure 513. Senior Western Pleasure
Please check boxes for the NSBA Futurity classes you wish to enter for Exhibitor #1:

(All Futurity classes have $1000 Added unless noted $5k class)
Hunter Futurities:

1. Hunter Yearling Longe Line - Non Pro 5. Maturity Hunter Under Saddle - Novice Rider / Novice Horse 7. Maturity Hunter Under Saddle - Non Pro 8. 3 YO Novice Horse Hunter Under Saddle - Open 9. 3 YO Hunter Under Saddle - Non Pro 13. 4 Year Old Hunter Under Saddle - Open - $5k Added 14. Hunter Yearling Longe Line - Open 15. 3 YO HUS - Limited Open 17. 3 YO HUS - Novice Rider / Novice Horse 18. Maturity HUS - $2,500 Limited Horse 21. HUS - Non Pro - Rider 50 & Over 28. Maturity HUS - Open 30. 3 YO HUS - Open - $5k Added
Western Futurities:

2. Western Yearling Longe Line - Non Pro 3. Super Sires Western Yearling Longe Line - Non Pro - **MUST ENTER WITH SUPER SIRES** 4. 3 YO WP - Limited Open - $5k Added 6. Maturity WP - Novice Rider / Novice Horse 10. Maturity WP - Limited Non Pro 11. Open Color Breed WP - All Ages 12. Novice WP - Non Pro - All Ages 16. 3 YO Western Pleasure - Novice Rider / Novice Horse 19. 4 YO WP - $5,000 Limited Horse - $5k Added 20. 3 YO WP - Limited Rider / $2,500 Limited Horse - $5k Added 22. 3 YO WP - Limited Non Pro 23. Maturity WP - Limited Open 24. Non Pro WP - Rider 50 & Over - $5k Added 25. Maturity WP - Non Pro / $2,500 Limited Horse 26. Western Yearling Longe Line - Open 27. Youth Western Pleasure - 18 & Under 29. 3 YO WP - Non Pro 31. Maturity WP - Open 32. 3 YO WP - Open 33. 2 YO WP - Open 34. 4 YO WP - Non Pro
EXHIBITOR #2 INFORMATION
Exhibitor #2 Name
Date of Birth:
MM/DD/YYYY
Relationship to Owner:
Yth. & Amt. must have valid relationship / Open=None
AQHA #:
AQHA Exp. Date:
MM/DD/YYYY
AQHA Membership Type:
NSBA #:
(If applicable)
NSBA Exp. Date:
MM/DD/YYYY
NSBA Membership Type:
Address if different from Owner

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
Phone Number
Please check boxes for the AQHA SE classes you wish to enter for Exhibitor #2:
AQHA Special Event / NSBA Dual Approved:

301. AQHA Level 1 Hunter Under Saddle 501. NSBA Level 1 Hunter Under Saddle 302. AQHA Youth Hunter Under Saddle 502. NSBA Youth Hunter Under Saddle 303. AQHA Select Hunter Under Saddle 503. NSBA Select Hunter Under Saddle 304. AQHA Amateur Hunter Under Saddle 504. NSBA Amateur Hunter Under Saddle 305. AQHA Junior Hunter Under Saddle 505. NSBA Junior Hunter Under Saddle 306. AQHA Senior Hunter Under Saddle 506. NSBA Senior Hunter Under Saddle 307. AQHA Youth Western Pleasure 13 & Und. 507. NSBA Youth Western Pleasure 13 & Und. 308. AQHA Level 1 Western Pleasure 508. NSBA Level 1 Western Pleasure 309. AQHA Youth Western Pleasure 14-18 509. NSBA Youth Western Pleasure 14-18 310. AQHA Junior Western Pleasure 510. NSBA Junior Western Pleasure 311. AQHA Select Western Pleasure 511. NSBA Select Amateur Western Pleasure 312. AQHA Amateur Western Pleasure 512. NSBA Amateur Western Pleasure 313. AQHA Senior Western Pleasure 513. Senior Western Pleasure
Please check the box for the NSBA Futurity classes you wish to enter for Exhibitor #2:

(All Futurity classes have $1000 Added unless noted $5k class)
Hunter Futurities:

1. Hunter Yearling Longe Line - Non Pro 5. Maturity Hunter Under Saddle - Novice Rider / Novice Horse 7. Maturity Hunter Under Saddle - Non Pro 8. 3 YO Novice Horse Hunter Under Saddle - Open 9. 3 YO Hunter Under Saddle - Non Pro 13. 4 Year Old Hunter Under Saddle - Open - $5k Added 14. Hunter Yearling Longe Line - Open 15. 3 YO HUS - Limited Open 17. 3 YO HUS - Novice Rider / Novice Horse 18. Maturity HUS - $2,500 Limited Horse 21. HUS - Non Pro - Rider 50 & Over 28. Maturity HUS - Open 30. 3 YO HUS - Open - $5k Added
Western Futurities:

2. Western Yearling Longe Line - Non Pro 3. Super Sires Western Yearling Longe Line - Non Pro - **MUST ENTER WITH SUPER SIRES** 4. 3 YO WP - Limited Open - $5k Added 6. Maturity WP - Novice Rider / Novice Horse 10. Maturity WP - Limited Non Pro 11. Open Color Breed WP - All Ages 12. Novice WP - Non Pro - All Ages 16. 3 YO Western Pleasure - Novice Rider / Novice Horse 19. 4 YO WP - $5,000 Limited Horse - $5k Added 20. 3 YO WP - Limited Rider / $2,500 Limited Horse - $5k Added 22. 3 YO WP - Limited Non Pro 23. Maturity WP - Limited Open 24. Non Pro WP - Rider 50 & Over - $5k Added 25. Maturity WP - Non Pro / $2,500 Limited Horse 26. Western Yearling Longe Line - Open 27. Youth Western Pleasure - 18 & Under 29. 3 YO WP - Non Pro 31. Maturity WP - Open 32. 3 YO WP - Open 33. 2 YO WP - Open 34. 4 YO WP - Non Pro
Submit Horse Papers, NSBA COE & all Membership Cards here:
Using a computer? Please use "Browse Files" button to attach documents.

Browse Files

Cancel of
Using a Tablet or Phone? Please use "Take Photo" button to take a picture.
Notes for Show Secretary:
# of AQHA Special Event Classes:
Enter the # of classes you are entering.
AQ SE Classes:
# of NSBA Special Event Classes:
Enter the # of classes you are entering.
NSBA SE Classes:
# of NSBA Futurity Classes with $1,000 Added:
Enter the # of classes you are entering.
NSBA $1k Classes:
# of NSBA Futurity Classes with $5,000 Added:
Enter the # of classes you are entering.
NSBA $5k Classes:
Total Entry Fees:
Total Other Fees:

Other Fees:

$ 8 AQHA Processing Fee

$ 8 NSBA Drug Processing Fee

$25 Office Fee

Total:
How would you like to pay?

Please charge my credit card. (I understand that I will incur a 4% convenience fee.) Print and mail form with a check.
Credit Card Fee:
Grand Total Due:

DISCLAIMER OF LIABILITY AND AGREEMENT

I accept any and all liability for any accident, loss, damage, injury or illness to any riders, horses, owners, spectators, property, vehicles and their contents and accessories or any other person or property whatsoever, whether caused by their negligence, breach of contract or in any other way whatsoever. Horses are entered at my own risk and are subject to AQHA & NSBA rules. In case of death, accident, injury or theft, to the exhibitor, their friends & family, horses, property, etc., no claims will be honored against Berrien County Fairgrounds, Back To Berrien Futurity, Show Management or Staff and all those associated with this show.

By signing below, I agree to these conditions.

Participant Signature (Parent or Legal Guardian must sign for minor exhibitors. Must be 18 to sign):
Use your mouse or finger to sign here:

Clear
Click Submit to complete your entry.
Click Print Form for your records or to print & mail.
If you are printing this form and mailing with check, click the "Print Form" button above and mail with payment to:

Make Checks Payable to: Back To Berrien

Fox Show Services

Back To Berrien

PO Box 88

Oxford, IA 52322
For Questions, please contact Chris Frese at 319-330-2215.
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