First Name

Last Name

Phone

Email Address

Address

Male/ Female

Age

Do you have any medical conditions or injuries that may prevent you from participating fully or that we should know about? Or any known allergies and (and medical response plan if required.)? Also please state an emergency contact name and phone number.

Please provide a brief description of your experience with horses if this is your first course with me.

Course location and dates

Participant Status Participant Status Participating with a Horse Participating without a Horse

Payment Payment PayPal (2.6% surcharge - you will be emailed a PayPal invoice on receipt of this registration form) Direct Deposit (see details in the right hand column)

Payment Option Payment Option Early Bird must be paid in full by EB date Full payment Deposit 50%

Declaration & Cancellation Policy Declaration & Cancellation Policy I have read and agree to the cancellation policy

Release and Indemnity Release and Indemnity I have Read and Agree to the Release and Indemnity

Permission to photograph and video Permission to photograph and video I have Read and Agree to the media release for video photographs

Comments, questions or message to facilitator, discount code if applicable.

Mailing List Mailing List Please add me to your mailing list for updates and news.

Signed

Date