Regional Certification Application

Regional Certification Application

May 31 & September 20 | Stone Gate Farm
Testing Dates & Registration Deadlines:

May 31 / Registration due by May 10

September 20 / Registration due by August 30

A non-refundable fee of $60 is due at time of submission which will be applied to the Facility Fee. Refunds will be considered with a vet or doctor’s note.

Testing fees will be due on the day of the testing:

D2/D3: $25/secion

C1: $35/section
Candidate Name*
Club/Center Name*
Club/Center Name
Current HM Certification*
HM Certification
Current Flat Certification*
Over Fences Certification
Current Over Fences Certification*
Over Fences Certification
Address*
City/State/Zip*
Mobile Phone*
E-Mail (enter parent e-mail if under age 18)*
example@example.com
Emergency Contact Name*
Relationship*
Mobile Phone*
E Mail*
example@example.com

Mount Information
Age*
Breed*
Gender*
Level of Training*
Rider's Current Competition Level*
Please upload a current negative Coggins *

Cancelof
Please upload proof of vaccination for Influenza and Rhinopneumonitis (EHV-1/4)*

Cancelof
If this horse was not available for the testing would you have a replacement?*

YesNo

Declarations

I understand that the facility fee is non-refundable. Additionally, I understand that my District Commissioner/Center Administrator will be contacted to verify that I am a member in good standing and supports me in my pursuit of the certification.
Candidate Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature (if a minor; if not a minor sign your name again)*

Clear
Date*

MonthDayYear
Date

Payment
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Grounds Fee
$60.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: