| Rider Name: | ______________________ | Owner Name: | ______________________ |
| Address: | ______________________ | Address: | ______________________ |
| | ______________________ | | ______________________ |
| | | | |
| Rider Phone: | ______________________ | Rider's Age: | ______________________ |
| Rider Email: | ______________________ | Rider's Level: | ______________________ |
| | | | |
| Horse's Age: | ______ Breed:_________ | Sex:____ | Height:_____ |
| | | | |
| Cost: |
| Current Students & Pony Clubbers | $85.00 one day | _____ |
| | $150.00 two days | _____ |
| Non-Students/Members | $115.00 one day | _____ |
| | $190.00 two days | _____ |
| Auditing | $25.00 per day | _____ |
| |
| *There will be an additional fee to be determined based on the clinician's air-fare. |
| *All fees are non-refundable and must be paid in full by December 1st, 2006. |
*Lunch will be provided.
|
| Date: ______________________ | Print Name:__________________ |
| Signature of Parent or Guardian: | Signature:____________________ |
| ___________________________ | |
Back to Clinic |