Mail-In Registration Form [Print Page 1]
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 "Print Form for Mail-In" button at the bottom of the form.
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 and 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?

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
Notice!!   Receipt of registration form and your donation fee guarantees your slot in the match.

When mailing in this registration form, enter the total donation amount in box below:
$ << Sorry, gotta do your own math.

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  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.
                                            _____________________________________
     Date                                                                                                       Signature
If Participant is under the age of twenty-one (21).   I << (Parent or Guardian) have read and understand this release and agreement.                                         ___________________________________
                                                   Date                                                                                                    Signature

                                 

Information:
Match Director
Lisa Tackett		 Print form and mail to >> (Make check or Money Order payable to:)
Lisa Tackett
714 Orchid Drive # C
Bakersfield, CA 93308
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.