National Examiner Mounted Clinic Rider Registration
Registration Due by March 16
Participant Info
Name
*
Age
*
Club/Center Name
*
Please Select
Bath Pony Club
Brush Run Pony Club
Harts Run Hunt Pony Club
Hunters Run Pony Club
Lost Hounds Pony Club
Rolling Rock Hunt Pony Club
Club/Center Name
Address
*
City/State/Zip
*
Mobile Phone
*
E Mail
*
example@example.com
Current HM Certification
*
Please Select
D3
C1
C2
HB
HA
HM Certification
Current Flat Certification
*
Please Select
D3
C1
C2
C3-DR
C3-FL
B-DR
B-EV
Over Fences Certification
Current Over Fences Certification
*
Please Select
D3
C1
C2
C3-EV
C3-SJ
B-EV
B-SJ
Over Fences Certification
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Current Competition Levels
If not currently competing, indicate the jump height you've been working at in the past month.
Flat
*
Over Fences
*
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Emergency Contact Info
Name
*
Relationship
*
Mobile Phone
*
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Mount Info
Age
*
Breed
*
Gender
*
Highest Competition Level
*
Please upload a current negative Coggins.
*
Browse Files
Drag and drop files here
Choose a file
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of
Please upload proof of vaccination for Influenza and Rhinopneumonitis (EHV-1/4)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Pay by Credit Card or PayPal
Registration Fees
*
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NE Clinic Auditor/Seminar Participant
One grounds person can attend for free with each rider. Use this field for any others attending with you in addition to your grounds person.
$
20.00
NE Clinic Flat Lesson Only
Can audit entire clinic
$
75.00
NE Clinic Jump Lesson Only
Can audit entire clinic
$
75.00
NE Clinic Flat & Jump Lesson
Can audit entire clinic
$
140.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
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