4-H Project Horse Eligibility/declaration Form - Virginia Cooperative Extension

Publication 406-125

County/Unit

4-H Project Horse Eligibility/Declaration

A completed signed copy of this form along with three clear photos of groomed horse (directions on second page)

must be submitted for each project horse. It is the 4-Hers responsibility to accurately complete and submit this

form to the Extension agent by May 1 of each year. 4-Hers not declaring their 4-H Project Horse(s) by May 1

of each year will be ineligible to exhibit their horse(s) at the District Qualifying Shows or Clinics and State 4-H

Horse Shows. The Extension agent will sign and date this form upon receipt and retain the original form.

Please Type or Print Neatly:

Member Information:

Name: _____________________________________________________________________________________

First

Middle

Last

Phone Number: ______________________ Email: ______________________ Date of Birth:_______________

Address: ___________________________________________________________________________________

Parent/Guardian: _____________________________________________________________________________

Club Information:

Club Name: _________________________________________________________________________________

Leader’s Name: _________________________________________ Leader’s Phone Number: _______________

Horse Information:

Horse’s Show/Registered Name: _____________________________ Horse’s Nickname: ___________________

Breed: __________________________________________________ Date Foaled: ________________________

Stabled at: __________________________________________________________________________________

Official Measurement (needs to be updated if animal is age 5 or under): __________ Date Measured: _________

Please circle the following that describes the horse/pony height category (see height reference on page 2):

Miniature

Small Pony

Medium Pony

Large Pony

or

Small Horse

Large Horse

If the project animal is leased or owned by someone other than a family member, please have the owner read

and sign below:

I give permission for the horse listed above and owned by me to be used as a 4-H project animal for the 4-H

member also listed above. I understand that the project year runs from Oct. 1 through Sept. 30.

Signature of Owner: ________________________________ Date: __________ Phone number: __________

Name and address of owner: _________________________________________________________________

The horse shown in the attached photographs and described on page 2 of this form is my project horse for the

_____________ 4-H year.* To the best of my knowledge the information provided is accurate and up to date.

4-H Member Signature: _________________________________________________ Date: _________________

Parent or Guardian Signature: ____________________________________________ Date: _________________

Leader Signature: ______________________________________________________ Date: _________________

Extension Agent Signature: ______________________________________________ Date: _________________

*If all information is correct for subsequent years, this form does not need to be resubmitted. Just initial and date for new project year.

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Tech, 2016

Virginia Cooperative Extension programs and employment are open to all, regardless of age, color, disability, gender, gender identity, gender expression, national origin, political affiliation, race, religion, sexual orientation, genetic

information, veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia

State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; M. Ray McKinnie, Interim Administrator, 1890 Extension Program, Virginia

State University, Petersburg.

VT/0316/4H-583P