2023 USCA MidCentral Regional Championship
October 13-15, 2023
Hosted by the Mid Central Illinois Schutzhund Club
Bourbonnais Township, Kankakee County, Illinois
Deadline! October 2, 2023
Entries received after this date will be assessed a $65 late fee
Handler Information
Handler Name
*
First Name
Last Name
Club Affiliation
*
If you are not affiliated with a club, please enter None
USCA Region
*
Please Select
Mid Central
Northwestern
Pacific Northwest
Southwest
North Central
South Central
New England
North Eastern
South Eastern
Other
Email and confirm your email
*
Confirmation Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Handler Address
*
Handler Street Address *
Handler Street Address Line 2
Handler City *
Handler State / Province *
Handler Zip / Postal Code *
Handler USCA Membership Number
*
Handler Membership Expiration
*
-
Month
-
Day
Year
Date
Club and Date where BH earned
*
Dog Information
Registered Name of Dog
*
Current Titles
*
Call Name
Tattoo / Microchip Number:
*
Registration Organization
*
USCA
SV
AKC
Other
Registration Number
*
Scorebook Number
*
Breed
*
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
BHOT (Breeder, Handled Owned and Trained)?
*
Yes
No
Is the dog
*
HOT (Handler Owned Trained)
BHOT (Breeder Handler Owner Trained)
None of the above
HOT (Handled Owned and Trained)?
*
Yes
No
Has the dog completed the USCA Breed Survey
*
Yes
No
Catalog Photo
*
Browse Files
Drag and drop files here
Choose a file
JPG, PNG, GIF only. 5MB size limit. Please submit a photo for the catalog and website. If you are not ready to submit today, you will find a link on your confirmation email to submit later. PREFERRED image size square, 1048 x 1048.
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Owner Information (only if different than Handler)
Owner Name (if different from handler)
First Name
Last Name
Owner Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner USCA Membership Number
Owner Membership Expiration
-
Month
-
Day
Year
Date
Release Statement
Release Statement
I agree to hold the organization (UScA), host club, property owners and any other member harmless and waive my right to pursue in court. I agree to follow all Local, State and Federal COVID-19 guidelines and agree to hold the organization, host club, and all property owners blameless for anything COVID-related that may result in my participation. I agree to be a good sportsman and follow all host clubs and property owner’s rules. I agree that I will clean up after my dog.
Photo Release
By submitting this form you are hereby granting permission to the Mid Central Illinois Schutzhund Club, the USCA Mid Central Region, the United Schutzhund Clubs of America or any official event photographer to use photographs and/or video of you and/or your dog taken at the 2023 USCA Mid Central Regional Championship in publications, news releases, online, and in other communications related to the mission of the USCA. Should you wish to opt out, please send an email with your name, your email address, and your dog's name to reanna2008@hotmail.com.
Type your full name below to indicate you have read and understood and agreed with this form:
*
Payment
Payment
You will be directed to PayPal where you can use your credit card or PayPal account to pay for your entry. A PayPal account is NOT required as you will have a choice to pay by credit card. ENTRY FEES ARE NON-REFUNDABLE. Should you need an alternate payment method, please contact ReAnna Scott at reanna2008@hotmail.com for a manual entry form.
Event Entry
*
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Pre-pay for Saturday Night Judges Dinner
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BH/VT Entry
Entry fees are non-refundable
$
155.00
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IGP 2 Entry
Entry fees are non-refundable
$
220.00
IGP 1 Entry
Entry fees are non-refundable
$
220.00
IGP 3 Entry
Entry fees are non-refundable
$
220.00
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