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AT
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Jumper Championship Series Entry Form
Championship 2024
Rider Information
Rider Name
*
Rider Name
First
First
Last
Last
Rider Age Category
*
Junior (<18) *If under 18, rider’s parent or guardian must sign form
Senior
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
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Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Email
*
Confirm Email
*
Phone
*
Emergency Contact Information
Emergency Contact Name
*
Emergency Contact Name
First
First
Last
Last
Emergency Contact Phone
*
Horse Information
I will be riding more than one horse
*
No
Yes (submit a separate entry for each horse)
Horse's Name
*
Negative Current Coggins Report
*
Upload File Now
File emailed to event secretary (
[email protected]
- Subject: Jumper Series Coggins)
File Upload
Drop a file here or click to upload
Choose File
Maximum file size: 18.87MB
Horse Name on Coggins (if different from above)
Horse Breed
*
Horse Height (in hands)
*
Horse Age
*
Horse Gender
*
Mare
Gelding
Sallion
Entry Information
Show date I am entering (select 1)
*
August 27, 2024 (Regular & Championship Classes)
Regular Class List ($30.00 per round)
*
0A. 1st Warm up round Unjudged
0B. 2nd Warm up round Unjudged
1A. Ground Poles
1B. Ground Poles Unjudged
2A. 12” Cross Rail
2B. 12” Cross Rail Unjudged
3A. 18” Cross Rail
3B. 18” Cross Rail Unjudged
4A. 2’
4B. 2’ Unjudged
5A. 2’3’’
5B. 2’3’’ Unjudged
6A. 2’6’’
6B. 2’6’’ Unjudged
7A. 2’9’’
7B. 2’9’’ Unjudged
8A. 3’
8B. 3’ Unjudged
9A. 3’3”
9B. 3’3’’ Unjudged
Championship Class List ($40.00 per round)
3C. - 18" Cross Rail Championship
4C. - 2' Championship
5C. - 2' 3" Championship
6C. - 2' 6" Championship
Championship Eligibility - You need to have participated in at least 2 shows in the specific class at a competitive level. Entry in the August 27th show in the regular class counts toward this requirement.
Special Requests &/or TIP Number
Liability Waiver
Paragraph
By submitting this form and payment I enter the WNRDC Jumper Series 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 WNRDC Jumper Series 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
*
signature
keyboard
Clear
Payment Information
Payment Total
$
Payment total includes a $5.00 processing fee
Cardholder Name
*
Cardholder Name
First
First
Last
Last
Cardholder Email
*
Cardholder Address
*
Cardholder Address
Cardholder Address
Cardholder Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Card Information
*
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