Application for Exemption by a Rider with Special Requirements

Application for Exemption by a Rider with Special Requirements
Rider's Full Name:*

First NameLast Name
Rider is over 18 years of age*

YesNo
Name of Parent / Guardian *

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Rider's Address*

Street Address

Street Address Line 2

CityState

Post Code
Select Rider's state*
This is because the application is sent to an authoriser in the rider's state
State email address
example@example.com
Is the rider a financial member of a Pony Club?*

YesNo
Pony Club membership ID*
Nature of the disability *
Date of onset of disability (if applicable)

DayMonthYear
Cause of disability*
Is the disability stable or degenerative?*

YesNo
Medical verification of the disability is required. A Doctor's Certificate giving the doctor's assessment of the nature of the disability and the amount of functional ability which the person retains is required. Please attach this document below. *

Cancelof
Present level of Competition*
Please list any compensating aids or adaptive equipment used by the applicant. *
Please detail any special equipment, saddlery or aids.
EXEMPTION DETAILS
Type of Exemption requested. Explain reasons in detail
Note: An exemption will not be granted if it:

         *           gives any rider an unfair advantage over other competitors

         *           adversely affects the safety of the rider

         *           adversely affects the welfare or well-being of the horse
Please attach any additional documents

Cancelof
Signature *

Clear
Signature of Parent/Guardian*

Clear
Should be Empty:

Application for Exemption by a Rider with Special Requirements

EXEMPTION DETAILS