Submit On-Line Registration Form
5 Dogs Action Shooters
 presents
16th Annual Silver Buckle Match
Bakersfield, California                May 21-23, 2010
What is our Economic Recovery Plan?       More Fun Lower Price !
2 Days of Shooting - 10 Stages - Just $85.00
Complete all details below and click on the "Submit" button at the bottom of the form.
Full Name:
Address:
City:  State: Zip Code:
Phone Day: Phone Evenings:
E-mail:     USPSA No:
Select
all that apply:		 Select Unclassified if you are shooting in your Category
     
 Lady     Junior      Senior     Super Senior 
Note: You may shoot in your Classification, or in a Category; not both.
** Juniors Shoot FREE!! (when accompanied by Paid Adult Shooter)
Check the box only if you are a Junior Shooter under 18 years of age.    
We need experienced ROs !               ROs & Staff will Shoot FREE!! on Friday & work Saturday and Sunday
 Check the box ONLY if you are an experienced RO and will work the match    
If you will work as RO - please answer the following question: Are you a Certified Range Officer?
Lunch is not included in the cost of the match, but our local Girl Scout Troop will be onsite selling breakfast, drinks, and lunch.  Please support the Troops!
There is plenty of room to dry camp at the range or several motels within a 20 minute drive.

Suggested Donation:  $85.00 - Juniors: ** FREE **
Donation Must be received by May 17, 2010
10 Stages - 250+ Rounds - Open Squadding
 Shoot - 8am - 4pm on Saturday and 8am - 1pm on Sunday
Payment Method:
(A Preview will be shown before Final Submission of the form)

Enter any additional comments in the space provided below:

Match Participation Release and Agreement Statement:
In consideration to participate in and/or observe the shooting competition, I hereby agree and release as follows. 
I [<<Name] do hereby release 5 Dogs Action Shooters and its' Board of Directors and officers, 5 Dogs Range, Inc., the United States Practical Shooting Association (USPSA) and all match sponsors from all liability which may arise out of any loss, damage, injuries or death which I may sustain.  This includes any theft, unexplained disappearance or damage that may befall my property accompanying me while en-route to or from, during participation of the event, or while on the premises where any of the match events occur.  I acknowledge I am over the age of twenty-one (21) and that I am aware of the risks and hazards inherent upon such events, including but not limited to, accidental discharge of firearms and loss of property through misplacement or theft.  I voluntarily assume all such risks.  I further state that I have read the foregoing participation agreement and release and freely enter into this event on behalf of myself and my distributes, heirs, next of kin, executors and administrators.
   I have read and understand the Match Participation Release and Agreement Statement. 
   ^ Date ^
If Participant is under the age of twenty-one (21). [Parent or Guardian Name>>]
[Parent or Guardian]   I have read and understand this release and agreement.    Date Signed:

                                                       
Note:   You will view a preview to double check your entries before final form submission.

Information:
Match Director
Lisa Tackett

Mail check or
Money Order to:

(Payable to:)
 Lisa Tackett
714 Orchid Drive # C
Bakersfield, CA 93308
If your check is not received by the deadline date (May 17, 2010) your entry will be removed from the match - ( WITHOUT NOTICE!! )
 Notice!!  Submission of this on-line registration form does not guarantee you a slot in the match, receipt of your donation fee guarantees your slot in the match.