Jumper Series Entry Form – West Newbury Riding & Driving Club

Rider Information

Name

First Name

Last Name

Rider Age Category

Junior (<18)

Senior

*If under 18, rider’s parent or guardian must sign form. Please enter Rider age below.

Rider Age (as of Jan 01, 2025):

Rider Contact Information

Address

City

State/Province

Zip/Postal

Phone

Confirm Email

Please confirm Email

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Horse Information

I will be riding more than one horse *

Yes*

*Please submit a separate entry for each horse

Horse's Barn Name *

Horse Name on Coggins

Enter horse name listed on Coggins if different than horse's barn name

Negative Coggins Report

Upload

eMailed to [email protected]

Coggins Report (Coggins report must be dated within 12 months of event)

Maximum file size: 8MB

ACCEPTABLE COGGINS: WITHIN ONE YEAR OF EVENT

Horse Breed

Horse Height (in hands)

Horse Age (in years)

Horse Gender

Mare

Gelding

Stallion

Liability Waiver

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

Clear

*If under 18, rider’s parent or guardian must sign.

Date

Payment Info

Payment Total

Payment total includes a $5.00 non-refundable processing fee.

Credit Card *

Cardholder Firstname *

Cardholder Lastname *

Cardholder Email *

Cardholder Address *

Cardholder Address

City

State/Province

Zip/Postal

Website/URL

If you are human, leave this field blank.

Jumper Series Entry Form 2025

Rider Information

Rider Contact Information

Emergency Contact Information

Horse Information

Entry Information

Liability Waiver