2023 No Frills Entry Form

1
Todays Date* This field is required.
Date
Year
Month
Day
2
Submission Type
Please Select
Please Select
Online
3
Rider AERC #Don't know your AERC number? You can find it on the AERC webpage Member Home/ My Info
4
Rider Name* This field is required.
First Name
Last Name
5
Weight Categories
These weights include all tack.

If you are not an AERC member, and estimate is fine.

J = Juniors (under the age of 16 on 12/1/2021)
FW = Featherweight (up to 160 pounds)
LW = Lightweight (161-185 pounds)
MW = Middleweight (186-210 pounds)
HW = Heavyweight (211 pounds and over)
6
AERC Weight Division* This field is required.Weight Categories
FW
LW
MW
HW
Junior
7
Does this horse have an AERC number?* This field is required.
YES
NO
8
Horse AERC NumberDon't know your horse's AERC number? You can find it on the AERC webpage https://aerc.org/membership/member-horse-lookup/
9
Horse Name* This field is required.
Enter TBD if horse is undecided
10
Ride day and Distance* This field is required.Select Which Day and which distance
55 Fri
30 Fri
55 Sat
30 Sat
Intro. Sat ONLY
11
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Phone Number* This field is required.
Please enter a valid phone number.
13
Email* This field is required.
example@example.com
14
Is this rider a Junior?* This field is required.
YES
NO
15
If Junior, riders birth date
Born after 12/1/2006
16
Sponsors NameIf rider is a Junior. (Born after 12/01/2006)
17
Horse Breed
18
Horse Gender
Gelding
Mare
Stallion
19
Horse Color
20
Horse Owner's Name* This field is required.
21
Upload Coggins (Current within the last 12 months)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
Is Rider a Member of ECTRA?
YES
NO
23
Rider ECTRA # (if applicable)
24
Horse ECTRA # (If applicable)
25
First AERC Ride?
YESNO
26
Are you an AERC Member?* This field is required.
YES
NO ($15 AERC Day Fee will apply)
27
OD Member?* This field is required.Is the rider a Member of the Old Dominion Equestrian Endurance Organization? (This is different from AERC Membership) Want to become an OD member and receive discounts on all ride entries and be eligible for the OD Triple Crown? Go to: https://www.olddominionrides.com/membership
YES
NO
28
Entry Fees (SELECT CAREFULLY PLEASE)* This field is required.Please choose carefully. OD MEMBERS select from the top 4 choices NON OD Members select from the BOTTOM 4 choices (Higher fees apply to non OD members)
55 Mile SENIOR OD Member
55 Mile JUNIOR OD Member
30 Mile SENIOR OD Member
30 Mile JUNIOR OD Member
55 Mile SENIOR NON OD Member
55 Mile Junior NON OD Member
30 Mile Senior NON OD Member
30 Mile Junior NON OD Member
Introductory Ride SATURDAY ONLY
29
Do you want to by Raffle Horse Tickets1 Ticket for $10, 3 tickets for $25, 5 tickets for $40, OR 10 tickets for $75
$10
$25
$40
$75
No Thank You
30
Calculation
31
Payment Method* This field is required.Mail checks to: Christine Roberts, 214 Burke St., Plains, PA 18705 If paying by Credit Card or PayPal please go to the OD website AFTER completing this form. https://www.olddominionrides.com/entry-forms and click on payment button
PayPal
Credit Card
Check (Mail to Ride Secretary)
Type option 4


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Todays Date	{todaysDate}
Submission Type	{submissionType}
Rider AERC #	{typeA}
Rider Name	{riderName}
AERC Weight Division	{aercWeight57}
Does this horse have an AERC number?	{doesThis}
Horse AERC Number	{horseAerc}
Horse Name	{horseName}
Ride day and Distance	{rideDay}
Address	{address}
Phone Number	{phoneNumber}
Email	{email}
Is this rider a Junior?	{isThis80}
If Junior, riders birth date	{ifJunior}
Sponsors Name	{sponsorsName}
Horse Breed	{horseBreed}
Horse Gender	{horseGender56}
Horse Color	{horseColor}
Horse Owner's Name	{horseOwners}
Upload Coggins (Current within the last 12 months)	{uploadCoggins}
Is Rider a Member of ECTRA?	{isRider81}
Rider ECTRA # (if applicable)	{riderEctra}
Horse ECTRA # (If applicable)	{horseEctra}
First AERC Ride?	{firstAerc30}
Are you an AERC Member?	{areYou}
OD Member?	{odMember}
Entry Fees	{ltspanStylefontsize}
Do you want to by Raffle Horse Tickets	{doYou}
Calculation	{calculation}
Payment Method	{paymentMethod}

Now create your own Jotform - It’s free!

Create a Jotform

33
After reviewing your responses and clicking submit: You have 2 more steps

PLEASE return to the OD webpage to complete your entry registration

Click on Liability Waiver and Treatment Authorization form sign and save them.

Then Click on the payment button: select either PayPal OR Credit Card and follow the instructions.

Once you have submitted your payment you should receive a confirmation email.

PLEASE forward the confirmation email to our NEW ride secretary Christne Roberts and attache the signed waiver and treatment form.

Christine Roberts: Ceroberts11@gmail.com

IF you selected Check, please mail your check and Waiver/Treatment forms to:

Christine Roberts: 214 Burke St., Plains, PA 18705
Should be Empty:

{form_title}