ESA PARA Performance Medals Scheme

RIDER INFORMATION
RIDERS NAME

First NameLast Name
RIDERS EA NUMBER
CLASSIFICATION GRADE
EMAIL
example@example.com
MOBILE
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Post Code
HORSE DETAILS
HORSE COMPETITION NAME
BRIDLE NUMBER
OWNER NAME (IF difference from rider)

First NameLast Name
OWNER EA NUMBER (IF Applicable)
COMPETITION LEVEL
PLEASE DIRECT ALL ENQUIRES TO

para.equestrian@equestriansa.com.au
MEDAL TYPE

QUALIFICATION SCORES

Rows	DATE	RIDER GRADE	TEST LEVEL	EVENT	SCORE	SCORING PLATFORM
SCORE 1
SCORE 2
SCORE 3

Scores will be verified by the ESA Para Equestrian Discipline committee.

All Enquiries can be directed to the PEDSA Committee

E: para.equestrian@equestriansa.com.au
PLEASE UPLOAD AN IMAGE OF YOU ARE YOUR HORSE AT COMPETITION

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PHOTO CREDIT (if applicable)
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