2025 Fort Valley Entry Form

1

Todays Date* This field is required.If you are registering AFTER the early bird deadline of Monday, Oct 6, 2025, An additional $50 will be added to your entry fee.

Date

2

Submission Type

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

AERC Weight Division* This field is required.These weights include all tack. If you are not an AERC member, and estimate is fine. J = Juniors (under the age of 16 on 12/1/2024) YR = Young Rider: For riders from 16-21 as of the first day of the ride season FW = Featherweight (up to 160 pounds) LW = Lightweight (161-185 pounds) MW = Middleweight (186-210 pounds) HW = Heavyweight (211 pounds and over)

FW

LW

MW

HW

Junior

YR

6

Horse AERC Number (does not have one, leave blank)Don't know your horse's AERC number? You can find it on the AERC webpage https://aerc.org/membership/member-horse-lookup/

7

Horse Name* This field is required.

Enter TBD if horse is undecided

9

Is this rider a Young Rider?YR-Young Ride (OVER the age of 16 on 12/1/2024)

YES

NO

10

Is this rider a Junior?* This field is required.J = Juniors (under the age of 16 on 12/1/2024)

YES

NO

11

If Junior, riders birth date

Born after 12/1/2008

12

Sponsors NameIf rider is a Junior. (Born after 12/1/2008)

13

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

14

Phone Number* This field is required.

Please enter a valid phone number.

15

Email* This field is required.

example@example.com

16

Emergency Contact InformationPlease provide a name and phone number of your emergency contact

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

22

Rider ECTRA # (if applicable)

23

Horse ECTRA # (If applicable)

24

First AERC Ride?

YESNO

25

Are you an AERC Member?* This field is required.

YES

NO ($20 AERC Day Fee will apply)

Intro Rider (no AERC fee charged)

26

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 (A $5 discount will be applied to your entry fee)

NO

27

Are you sponsoring a Junior in the 30 or 50 Mile distance?($20 discount for Sponsors) Does NOT APPLY for the INTRO Ride)

YES I am sponsoring a junior in the 30 or 50 (A $20 discount will be applied to your entry fee)

No

28

Entry Fees (SELECT CAREFULLY PLEASE)* This field is required.IF YOU ARE REGISTERING AFTER Oct. 6th (Early Bird Deadline), AN ADDITIONAL $50 will be applied to the amount listed below DOES NOT APPLY TO INTRO RIDERS Please choose carefully: Prices listed below are Early Bird Prices OD members will receive a $5 discount applied at the end

50 Mile SENIOR ($135)

50 Mile JUNIOR ($110)

30 Mile SENIOR ($115)

30 Mile JUNIOR ($90)

Introductory Ride SATURDAY ONLY ($50)

29

Would you like to buy extra FRIDAY dinner meal tickets? $15 eachOne Friday meal ticket is included in ALL entry fees for ALL distances.

1 Meal Ticket ($15)

2 Meal Tickets ($30)

3 Meal Tickets ($45)

4 Meal Tickets ($60)

5 Meal Tickets ($75)

30

Do you want to buy Raffle Horse Tickets1 Ticket for $10, 3 tickets for $25, 5 tickets for $40, OR 10 tickets for $75

$10 (1 ticket)

$25 (3 tickets)

$40 (5 tickets)

$75 (10 tickets)

No Thank You

31

Payment Method* This field is required.REFUND POLICY: Scratches BEFORE the early bird deadline (October 6th )Full Refund minus $25 non-refundable deposit After Oct. 6th: Refunds minus a $50 non-refundable deposit will be issued up through Sunday, Oct. 12th Oct. 12th-15th a partial refund will be issued on a case by case basis. NO REFUNDS after Wednesday, Oct.15th Mail checks to: Carolyn Blocker, 2517 Vineyard Lane, Crofton, MD 2114 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 (A $3 service charge will be added to you total)

Credit Card (A $3 service charge will be added to your total)

Check (Mail to Ride Secretary) (NO FEE added)

ZELLE (Use your Zelle account, make payment to (payment@odeeo.org) Bank to Bank transfer NO FEE

Other

32

Calculation (If you feel the TOTAL is incorrect contact the ride Secretary) (DO NOT CHANGE IT HERE OR YOUR ENTRY WILL BE INVALID)The Early Bird Discount price ENDS at midnight, Oct. 6th.

33

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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 Young Rider?	{isThis105}
Is this rider a Junior?	{isThis}
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}
Are you sponsorring a Junior?	{areYou99}
Entry Fees	{ltspanStylefontsize}
Do you want to buy an extra meal ticket?	{wouldYou}
Do you want to by Raffle Horse Tickets	{doYou}
Payment Method	{paymentMethod}
Calculation	{calculationif}

Now create your own Jotform - It’s free!

Create a Jotform

34

ALMOST DONE:

After reviewing your responses and clicking submit: YOU HAVE 2 MORE STEPS

PLEASE return to the OD webpage to complete your entry registration

STEP 1: Liability Waiver and Treatment Authorization Form:

Click on Liability Waiver and Treatment Authorization form sign and SAVE THEM TO YOUR COMPUTER

STEP 2: Scroll down and click on the payment button: select either PayPal OR Credit Card and follow the instructions.

IF paying by Zelle go to your Zelle account and make payment to (payment@odeeo.org.) This is a bank to bank transfer. Save your confirmation of your transaction and forward to Carolyn Blocker. See below

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

PLEASE FORWARD the confirmation email to the Ft Valley ride secretary Carolyn Blocker AND ATTACH the signed waiver and treatment form.

Carolyn Blocker: eagleonvineyard@msn.com

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

Carolyn Blocker, 2517 Vineyard Lane, Crofton, MD 2114

{form_title}