PHHT Entry Form – West Newbury Riding & Driving Club

Rider's Information

Riders Name

First

Last

Rider Age Category

Senior

Junior(<18), (parent/guardian must sign form)

Address

City

State/Province

Zip/Postal

Phone

Confirm Email

Emergency Contact Information

Emergency Contact's Name

First

Last

Emergency's Contact Phone

Horse Information

I will be riding more than one horse

Yes (submit a separate entry for each horse)

Horse's Name

Horse's Name on Coggins (if different than above)

Negative Current Coggins Report

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File emailed to Event Secretary (Coggins@wnrdc.com)

Horse Breed

Horse Height (in hands)

Horse Height (in hands) cannot be blank.

Horse Age (in years)

Horse Age (in years) cannot be blank.

Horse Gender

Mare

Gelding

Stallion

Horse's T.I.P. Number

Liability Waiver

Paragraph

By submitting this form and payment I enter the Pipestave Hill Horse Trials which is made at my own risk and subject to the conditions of the sponsoring Club. Further, in doing so, I understand that this competition can be dangerous for both horse and rider, including sickness and disease (including communicable diseases.) In addition, I release the West Newbury Riding and Driving Club, its members, all volunteers, the Town of West Newbury, landowners, and organizers from any and all liability actions, causes of action, claims and demands of every kind and nature whatsoever which may arise in connection with or resulting from participation in any activities. I also give permission for the WNRDC to use any photograph, video or other likeness of me and my horse taken during the Pipestave Hill Horse Trials for promotion, coverage, or benefit of the club, with the condition that such likeness will not be used to commercially promote any product. I hereby expressly and irrevocably waive and release any rights in connection with such use, including any claim to compensation, invasion of privacy, right of publicity, or to misappropriation.

By electronically signing my name below, I agree. If under 18, the rider’s parent or guardian must electronically sign.

Signature (parent must sign for minor)

Clear

Date

Payment Information

Payment Total

Payment total includes a $5.00 processing fee

Cardholder Name

First

Last

Cardholder Email

Cardholder Address

City

State/Province

Zip/Postal

Card Information

If you are human, leave this field blank.

Pipestave Hill Horse Trials Entry Form

Rider's Information

Emergency Contact Information

Horse Information

Entry Information

Liability Waiver

Payment Information