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Nebraska High School Rodeo Association
STATE ASSOCIATION SECRETARY
Becky Dailey PO Box 10, Arnold, NE 69120
PHONE: 308-539-6543 FAX: 308-848-2544
2011-2012 Membership Application
PLEASE PRINT CLEARLY OR TYPE—Sign ALL Forms
Rookie (1st Year)
Name of Parent(s)/Guardian(s):
fee $175 (Competing) $111.00 (Associate). This fee goes for-National Dues $38,
NHSRA Times Newsletter $15, Western Horseman $2.00, Insurance $69 (Competing) or $10 (Associate),
State dues $32, Fence Post Subscription $9, and one Adult Membership $10.
Nebraska High School Rodeo State Entry Form. *Both parents and member or legal guardian must
sign this form by each event the contestant competes in. Events must be marked and signed to
compete at the practice rodeos
. If only one parent is signing, please note reason on signature
line. For example Full custody, Divorced, Deceased. Must be notarized.
National High School Rodeo Membership Form. Both parents and member or legal guardian must
sign this form on the front and back. If
only one parent is signing, please note reason on signature
line. For example Full custody, Divorced, Deceased. Must be notarized.
A Grade Transcript
for the prior semester must accompany application form. It must have a school official’s
signature and/or school seal. Incoming freshman may provide a report card instead of a transcript. If you are a renewing member, your transcript should be on file. NOTE: you will have to submit a Grade Transcript after each semester to ensure that you are passing four classes each semester. Fax number 308-848-2544
: Members are required to sell 10 calendars @ $20 each turned in by March 1. After, March 1
you will owe $200 plus a fine of $60 for a total of $260 ($60 fine would not apply to new members that
join after March 1). There will be no calendars available to sell after March 1.
The Nebraska High School Rodeo Association is publishing a NEBRASKA RULE BOOK AND DIRECTORY
. We would
like to use your name, parents name, address, phone number, email and grade. The directory will be available only to
Nebraska High School members. If you do not wish to share this information please initial
2011-2012 NEBRASKA HIGH SCHOOL RODEO Contestant Name:
**MARK THE EVENTS YOU WISH TO ENTER AT ALL QUALIFYING
**BOTH PARENTS MUST SIGN NEXT TO EACH EVENT YOU ENTER**
Before me, the undersigned Notary Public, duly commissioned and qualified within and for said county and State, personally appeared
Parent(s) or guardian(s) of the above applicant, who, upon their oath, each depose and say “THAT WE HEREBY GIVE CONSETS FOR
THE SAID APPLICANT TO PARTICIPATE IN SAID NEBRASKA STATE AND PRACTICE HIGH SCHOOL RODEO(S) TO BE HELD IN THE STATE OF NEBRASKA. THAT WE HOLD ALL SPONSORING ORGANIZATIONS AND INDIVIDUALS HARMLESS FROM ANY LIABILITY WHATSOEVER BY REASON OF HIS OR HER PARTICIPATION IN SAID RODEO(S). IN CASE OF INJURY, PERMISSION IS HEREBY GIVEN ANY DOCTOR, HOSPITAL, OR PARAMEDIC PROFESSIONAL TO RENDER WHATEVER EXAMINATION OR TREATMENT THAT MAY BE NECESSARY ON BEHALF OF SAID CONTESTANT PARICIPANT. We also acknowledge that we are familiar with the rules of the NHSRA and approve the same and will abide by said rules on behalf of said contestant participant.”
SUBSCRIBED in my presence and sworn to me before this
SECRETARY USE ONLY
Membership # Issued
(Please Print or Type)
Mailing Address:____________________________________________________ Telephone: (_______) __________________
City, State/Province: _________________________________________Zip+4 / Postal Code: ____________________________
Country:_______________________ Gender (circle one): Male Female Cell Phone: (_______)____________________
State/Province Attending School In:__________________________ School Type (circle one): Public Private Home
Date of Birth: Month__________ Day___________ Year___________ Current Grade in School (circle one): 9 10 11 12
Age as of August 1, 2011 _____________ Were you previously a member of the NHSRA Junior High Division? ____________
State/Province Association in which you are applying for membership:_______________________________________________
If you live in a different state than the one you are applying for membership in, have you submitted a signed transfer form? ______
Which Region/District (if applicable):_________________ Years in NHSRA (circle one): 1 2 3 4 (include current year)
Check one: ________ Rookie (1st year) Member __________ Renewing Member
Type of Membership (check one): ____________ Competing ____________ Associate
(Competing members are eligible to enter events at qualifying rodeos, compete for awards and scholarships and qualify for the National High
School Finals Rodeo. Associate members are not eligible to enter rodeo events. Both categories of membership are eligible for additional
benefits from the region/district, state/province and the NHSRA as may be currently offered.)
Dues and Fees:
IMPORTA T - PLEASE I ITIAL
Western Horseman, and Insurance . .$124.00 (U.S.) or $65.00 (Foreign)
I understand that I receive a one-year subscription to
State/Province Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $________
magazine as a benefit of my
Region/District Dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $________OR
NHSRA membership (non-waivable).
“Associate Member” (Non-competing) $40.00 (U.S.) or $50.00 (Foreign) my NHSRA membership dues will be applied to this
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$________
one-year subscription. (Initial here)
EVE TS (Competing Members Only)
Would you like to participate in sponsor surveys and
(As a competing members you are eligible to enter any of the events offered for your
focus groups, or receive email updates on NHSRA
gender. For statistical purposes, please check any and all of the events you are planning
Programs and Sponsor Promotions? _________
If you are a new member, how did you learn
about the HSRA?
READ AND SIGN BELOW:
We certify that the information supplied in this application is true and correct to the best of ourknowledge and belief and that the student applying for membership meets the qualifications and criteria for membership in the District/Region High SchoolRodeo Association, the State/Province High School Rodeo Association and the National High School Rodeo Association. By applying for and receiving mem-bership in the District/Region, State/Province and National High School Rodeo Association, we hereby agree to follow all rules and guidelines set forth by theRegion/District, State/Province and the National High School Rodeo Association and to abide by all decisions and rulings of the governing committees andboards of these associations.
Member Signature: X_________________________________________________________________________ Date:_______________________________
Mother’s Signature: X________________________________________________ Father’s Signature: X _________________________________________
(BOTH PARENTS AND/OR GUARDIANS MUST SIGN APPLICATION!)
COMPLETE THE RELEASE FORM ON THE REVERSE SIDE OF THIS APPLICATION.
NHSRA Membership #_____________________
NATIONAL HIGH SCHOOL RODEO ASSOCIATION
MEMBER’S NAME____________________________________________________________________ SOC. SEC. #___________________________
ADDRESS ______________________________________________ CITY________________________ STATE ________ ZIP___________________
TELEPHONE # _____________________________ AGE: MM______ DY _____ YR _____ EFFECTIVE DATE: __________________________
MINOR’S RELEASE, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
We, the undersigned, hereby request that the below named minor (minor) be granted permission (1) to enter the restricted area, (2) to participate
as a contestant, assistant, official or otherwise in rodeo events, (3) to compete for money, prizes, recognition or reward, (4) to be covered by
participants’ hospitalization insurance, if applicable, as limited by the master policy (all collectively hereinafter called “permissive entry”).
In consideration of “permissive entry” to minor into the restricted area, which is the area from which admission to the general public is restricted,
which includes, but is not limited to the rodeo arena, competition area, chutes, pens, adjacent walkways, concessions, and other appurtenances, we,
the undersigned, on behalf of the minor and for ourselves, our personal representatives, heirs, next of kin, spouses and assigns, do hereby:
1. RELEASE, DISCHARGE AND COVENANT NOT TO SUE the rodeo committee, stock contractor, rodeo association, sponsors, arena operators
or owners, and each of them, their officers, agents and employees (all hereinafter collectively referred to as “releasees”) from any and all claims and
liabiltiy arising out of strict liability or ordinary negligence of releasees or any other participant which causes the undersigned injury, death, damages or
property damage. We, the undersigned, jointly, severally, and in common, covenant to hold releasees harmless and to indemnify releasees from any
claim, judgement or expenses releasees may incur arising out of any of the minor’s activities or presence in the restricted area.
2. UNDERSTAND that minor’s entry into the restricted area and/or participation in rodeo events contains DANGER AND RISK OF INJURY OR
DEATH TO MINOR, that conditions of the rodeo arena change from time to time and may become more hazardous, that rodeo animals are dangerous
and unpredictable, and that there is INHERENT DANGER in rodeo which we each appreciate and voluntarily assume because the minor and we
choose to do so. Each of the undersigned has observed events of the type that the minor seeks to participate in. We further understand that the arena
surface, access ways or lack thereof, lighting or lack thereof, and weather conditions all change and pose a danger to the minor. We further understand
that other contestants and participants pose a danger to the minor, but nevertheless, WE EACH VOLUNTARILY ELECT TO ACCEPT ALL RISKS
connected with the minor’s entry into the restricted area and/or participation in any rodeo events.
3. AGREE that this agreement shall apply to any incident, injury, accident or death occurring on the above date and FOR A PERIOD OF
ONE (1) YEAR THERAFTER or until the minor’s association membership expires, whichever shall last occur. All subsequent agreements and
release documents signed by any of the undersigned shall amplify, but shall in no way limit the provisions of this document. The provisions of
this document may be cancelled by any one of the undersigned by delivering to the above rodeo association written cancellation of this
agreement which shall be effective 24 hours after the date said cancellation is actually received by the rodeo association.
4. Releasor or parents or guardians of the undersigned minor AGREE TO INDEMNIFY the Releasees and each of them from any loss,
liability, damage or costs they may incur due to the presence or participation of the minor in the described activities whether caused by the
negligence of the Releasees or otherwise.
WE HAVE READ THIS DOCUMENT, WE UNDERSTAND IT IS A RELEASE OF ALL CLAIMS.
WE APPRECIATE AND ASSUME ALL RISKS INHERENT IN RODEO. AND*
Signature of Natural Father
, to me known to be the persons who executed the foregoing Release and acknowledged that they
signed same as their free act and deed. My Commission Expires:
*Both parents and member or legal guardian must sign this form in the appropriate places above. If only one parent is signing, please note reason on signature line. For example, DECEASED, DIVORCED AND FULL CUSTODY, ETC. All signatures must be witnessed by a notary and listed as personally appearing in the appropriate place on the form. Be sure that notary signs, dates and places his/her seal on the form. Please return original Minor’s Release form to the state/province secretary with membership application and fees.
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