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_______________________