2023 Central District Qualifying Clinics and Skills Testing

Name of Applicant

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date

Age of Applicant as of Sept. 30, 2022

Phone Number

Email

example@example.com

County

Club

District

Coggins Accession#

Date Drawn

Date

State

Name of Horse

Height of Horse

Breed

Color

Age of Horse

Check all that you wish to attend:

Saturday, March 19, 2023, 9am-4pm (entries due by March 1st)

Intro to Western DressageSkills Test Level 1Skills Test Level 2Measurements Needed

Saturday, May 21, 2023, 9am-4pm (entries due by Mary 1st)

Balanced Seat & Show Ring Etiquette Clinic SkillsSkills Test Level 1Skills Test Level 2Measurements Needed

Start times is 9:00am. Upon arrival all participants will turn in a copy of their equine's current negative coggins, exhibitor health history, complete all waivers, and paperwork before unloading. All Participants are expected to be appropriately chaperoned and always supervised. If you are traveling without a parent to sign waivers, please notify us in advance. Please send all paperwork to:

Danielle Toms Kernen 2965 Hat Creek Rd Brookneal, Va. 24528 RSVP for Clinic: 540-874-0377 or hatcreekequestrian4hclub@gmail.com

I agree to participate under the rules of 4-H and this clinic and agree that neither the event nor sponsors will be responsible for any accident or injury to the person or property of any participant or other person. The participant agrees to indemnify the event organizers and Hat Creek Equestrian against any claim or liability for damage caused by him or his animal. The applicant and/or representative hereby agree to abide by all rules for this 4-H including the entry system. Participant and parent or guardian hereby attest that they read the rules for this event and that this applicant and entry meet all rules and regulations for this event.

Signature of PARTICIPANT

Clear

Signature of PARENT/GAURDIAN,

Clear

Signature of CLUB LEADER

Clear

Please Mail or email this application, a copy of your health history form, equine waiver, and entry fee to Danielle Kernen 2965 Hat Creek Road, Brookneal, VA 24528 or email: hatcreekequestrian4hclub@gmail.com.