Clinic Entry form Please enable JavaScript in your browser to complete this form.Name of Clinic *Date(s) of Clinic *Date of EventRIDER Name *FirstLastName of RiderRider's Mailing Address *Rider’s Mailing Address: Street/PO Box Apt # etc/City/State/zipRider's Email *EmailConfirm EmailRider’s Email – How to contact with Ride Times, etc.Rider's Phone Number *Rider’s Phone (###) ###-####Emergency Contact Information *Emergency Contact: Name/phoneHORSE Full Registered Name/Barn Name and Information *Horse’s Full Registered Name/ Barn Name Breed/Sex/Height/Color/AgeVaccinations and Coggins Information *VACCINATIONS AND COGGINS – INCLUDE ATTACHMENTS most recent copy. Coggins valid within one year of show date. USEF Vaccine Log within 6 months of show date. Please note dates aboveOWNER'S Name *FirstLastName of Horse OwnerOwner Mailing Address *Owner Mailing Address: Street/PO Box Apt # etc/City/State/zipRiding Level/Discipline/Test *Riding LevelDiscipline (Western, Eventing, Dressage, OtherSpecific Test(s)Any Special Requests?Fill In any that apply!Clinic Fees *Per Ride FeeClinic Sponsorship (Optional)Other Fees (eg. Local Membership fee, non Competing Horse, etc.)REFER TO Clinic Flier FOR $$ AMOUNTS. Questions? Please contact Show Secretary. Thank You!RELEASE, WAIVER AND HOLD HARMLESS AGREEMENT SIGNATURE RELEASESignatures *Rider/Driver/Handler/Vaulter/Longeur (mandatory)Is Rider/Dirver/Vaulter a U.S. Citizen (check if Yes)Owner/Agent (mandatoryParent/Guardian:print name/Sign (If applicable)Please PRINT then Sign Name. Submit