2021 USMRA National Championships Trial Entry Form

April 1-2, 2023

Willow Tree Ranch

5274 Poplar Road

Vacaville, CA 95687

*This entry form will automatically become unavailable at 23:59 PDT (Pacific Daylight Time) on Monday, January 30th, 2023.*

Handler's Name*

First NameLast Name

Handler's USMRA Member Number*

Handler's Phone Number*

Area CodePhone Number

Handler's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Handler's Email Address*

USMRA 2023 Club Affiliation*

Additional USMRA 2023 Club Affiliation

Dog's Registered Name*

Dog's Date of Birth*

Date

Dog's Sex*

MaleFemale

Spayed / Neutered?*

YesNo

Dog's Breed as listed in Score book*

Dog's Score book # - Organization and Number*

Dog's Recall*

WhistleVoice

Is Dog FCI Registered*

YesNo

Dog's FCI Registration Organization Name & Number*

Tattoo/Microchip Number*

Will dog be in heat during event?

Judge: Emma Svensson (Sweden)

Decoys: Level 3 - NaKe Florin (United Kingdom)

Level 3 - Francois Massart (USA)

Level 2 - David Wright (USA)

Theme: Carnival Chaos

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MR1 and MR2 competitions to be held Saturday, April 1, MR3 competition to be held Sunday, April 2, followed by the closing ceremony (subject to change)

Entry Fee $150.00. All entries are final. Refunds for all entries that are not accepted due to capacity limits. ENTRIES CLOSE: January 30, 2023 at 23:59 PST.

Level you are registering for:*

MR1 (Tentaively scheduled for April 1)MR2 (Tentatively scheduled for April 1)MR3 (Tentatively schedule for April 2)

By submiting this form, I authorize USMRA and the hosting club (Synergy Ringsport), to use the following personal information:

(1) My picture - including photographic, motion picture and electronic (video) images.

(2) My voice - including sound and audio/video recordings

I hereby grant USMRA and the hosting club the right to use, publish and reproduce, for all purposes, my name, pictures of me in film or electronic (video) form, sound and video recordings of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition, distribution, promotion, advertising, press conferences and in brochures and other printed media. This permission extends to all languages, media, formats and markets now known or hereafter devised.

* PLEASE READ CAREFULLY By submitting this application, I attest that this information is correct and true, to the best of my knowledge. I understand and I agree to abide by the USMRA Code of Conduct, rules and regulations of the USMRA (United States Mondioring Association), policies and procedures and it's stated purposes of promoting Mondioring, sportsmanlike conduct and fair and humane training at all dog sport activities. I agree to keep myself informed on current by-laws, and policies and procedures of USMRA via the www.usmondioring.org website, OFFICIAL communications, or by requesting a copy from the USMRA Secretary. It is hereby understood that every dog at this event will be under the direct care of its handler. The undersigned agrees to be fully responsible for any and all actions of themselves and their dog(s), including dogs owned by another, but in the undersigned's care. I agree to hold harmless all members, officers and directors of USMRA, the Hosting Clubs as listed above, and any property owners associated with this event in case of accident or injury. Any and all score protests will be submitted in writing to a member of the trial organizing committee at the event only. No protests will be heard after the closing ceremony, and all decisions concerning any protests will be made by the time of the closing ceremony and shall be final. I the undersigned do hereby verify that my dog(s) is/are healthy and current in his/her required vaccines, and I assume all responsibility and liability for myself and my dog(s).*

Agree

Signature*

Today's Date:*

Date

Please provide your Dog's USMRA issued Dog Identification Card with this entry form

Please provide your dog's USMRA issued Dog Identification Card*

Please write a short bio for you and your dog to be highlighted on the National's Facebook page and website.*

Please list your passing score(s), date received and for which level.*

Please provide your favorite image of you and your dog to accompany your bio on the National's Facebook page & website. *

Please include a picture of your passing score(s) from your dog's scorebook.*

National Championship Entry Fee using PayPal*

National Championship Entry Fee$150.00

Handler Information

Dog Information

Trial Entry Information

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