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Northern Virginia VPG Club
USCA - Trial Entry Form
Trial Entry [ ] BH $75 [ ] STP 1 $50 [ ] STP 2 $50 [ ] STP 3 $50
[ ] TR 1 $50 [ ] TR 2 $50 [ ] TR 3 $50 [ ] OB 1 $50 [ ] OB 2 $50 [ ] OB 3 $50
[ ] IPO 1 $85 [ ] IPO 2 $85 [ ] IPO 3 $85 [ ] FH 1 $85 [ ] FH 2 $85
Registered Name of Dog ____________________________________________________________
Date of Birth __________________
[ ] Male [ ] Female Breed ______________________________________________
Scorebook # ______________________ Dogs Registration # ______________________
Tattoo/ Microchip# ________________________________________________________________
Owner’s Name ___________________________________________________________________
Owner’s Address _________________________________________________________________
City ____________________ State _________________ Zip _____________
Owner’s Phone __________________ Other Phone _____________________
USCA Member Number __________________________
Club Name ____________________________________________
Handler Name:
_____________________________________________________________________________________
Handler Address:
City __________________________________ State _________ Zip _____________
Handler Phone ________________________ Other Phone _________________________
Handler E-Mail ________________________________________
Date and Organization where Handler achieved BH:
__________________________________________________________
USCA Member Number __________________________
Club Name ____________________________________________
Please make checks or money orders payable to: Podium Club.
Payment MUST accompany entries.
Send Entries to:
Mrs. Sabine Ernsting
137 Egypt Rd.
Kearneysville, WV 25430
Release Statement
It is understood that every dog at this event will at all times be in the care and control of the dog's handler. It is further understood that the undersigned agrees to be fully responsible for the actions of that dog, while on the show grounds. I agree to hold the Northern Virginia VPG Club, the American Kennel Club, and the United Schutzhund Clubs of America, as well as their members, officers, directors, and all property owners harmless for loss or injury which may have been caused directly or indirectly to any person or thing by any act of my dog(s) while on the show premises. I hereby assume all responsibility and liability for such claims.
Owner or Agent __________________________________________ Date_______________________
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