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Rider Name _______________________________________________________AERC#_________________AGE_____________

Address ___________________________________________________________Phone _________________________________

City ________________________________________________________________State _________________Zip _____________

Horse Name_______________________________________________________AERC#__________________AGE____________

Breed _________________________________________Sex____________Color/Markings________________________________

Owners Name_____________________________________________________AERC# __________________________________

Owners Address ___________________________________________________________________________________________

CATEGORIES-PLEASE CHECK:(Wt. Divisions equal rider's weight plus tack.)

Junior _________Birth date __________________________Featherweight (160# below) __________________

Lightweight (161-185#) _____________ Middleweight (186-210#) _______________ Heavyweight (211# up) ______________

As a participant in the Mariposa 25 or 50 Mile Ride, I agree to abide by the rules of AERC and by the rules of this ride. I understand that
endurance riding involves being in remote areas for extended periods of time, far from communication, transportation and medical facilities,
that these areas have many natural and man-made hazards which Ride Management expressly declines to anticipate, identify, modify or
eliminate or warn against; that horses can be excitable, difficult to control and unpredictable; and that accidents can happen to anyone at
any time. I agree to take full responsibility for myself, and the animal I am riding. I release, hold harmless and indemnity the Mariposa
Mountain Riders, "Run For The Gold" Ride Management, all ride personnel, Bill Parker, Circle 9 Ranch, U.S. Forest Service and all
liability arising from accident, injury or loss that might occur due to my participation in the ride.

I HAVE READ AND UNDERSTAND THIS LIABILITY RELEASE.

Riders Signature ______________________________________________________________Date _________________________

I give permission for emergency medical treatment:

Parent or Guardian of Junior Rider______________________________________________________________________________

Sponsor of Junior Rider______________________________________________________________________________________

Juniors & 2005 Ride Managers are 1/2 Price Entry Fee

_________25 Miler-----------------------------------$ 80.00 - total $ ___________________________

_________50 Miler-----------------------------------$ 90.00 - total $ ___________________________

_________Non- AERC Member ADD-------------$ 10.00 - total $ ___________________________

_________Friday Dinner---------------------------$ 5.00 - total $ ___________________________

_________Extra Saturday Banquet---------------$ 10.00 - total $ ___________________________

_________Late Entry ADD---After June 18th----$ 20.00 - total $ ___________________________

Total Due---------------------$ ___________________________

Make Checks Payable to: MARIPOSA MOUNTAIN RIDERS

Mail Check and Entry form to: Bill Parker ~ 3038 Poppy Lake Road, Mariposa, CA 95338