Toms Performance Horses, LLC Christmas Pole Dancing Clinic Registration Form
December 12, 2026
Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Riders Age:
Experience:
Goals:
Horse's Name:
COGGINS Lab Access No.
State
Test Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Registration form and non-refundable fees due December 1st
Spot is not held until full fee is paid. Spots are limited so get signed up ASAP
Check payable to:
Toms Performance
Horses, LLC
2965 Hat Creek Rd
Brookneal, VA 24528
Electronic Payments
Venmo:
Danielle-Kernen (0377)
PayPal
friends and family: DanielleToms80@gmail.com
I, the handler or guardian of the minor (under 18), enter the above horse at my own risk subject to all rules and regulations of the show and Hat Creek Equestrian. I agree if any injury or death occurs to the animal exhibited, myself or minor exhibitor, spectators, or damage to any personal property on the grounds, that I hereby waive and release any claim to liability whatsoever from Hat Creek Equestrian, all committees, property owners, employees, members, and volunteers whether the injury, death, or damage be caused by gross negligence or simple negligence of Hat Creek Equestrian.
Exhibitor Signature (or guardian if under 18)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Submit
Should be Empty: