Hunter Derby Entry Form – West Newbury Riding & Driving Club

Rider Information

First Name

Last Name

Rider Age Category

Junior (<18 as of Jan 01)

Senior

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

Rider Age on Jan 01, 2025:

Rider Contact Information

Address

City

State

Zip/Postal

Phone

Confirm Email

I will be traveling:

Alone

With my barn

Barn Name

Trailer Size

2 Horse Trailer

3+ Horse Trailer

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone

Horse Information

I will be the warm up rider *

No (submit separate entry for warmup rider)

Yes

Horse's Barn Name *

Horse's Name on Coggins

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

Negative Current Coggins Report

Upload now

Coggins 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

TIP Number

Warm Up

$35

Judged Divisions

Judged Divisions (maximum of 2)

18" - 2' Cross Rail Derby ($55)

2' - 2'3" Derby ($85)

2'3" - 2'6" Derby ($85)

2'9" - 3' Derby ($85)

3' - 3'3" Derby ($85)

Special Requests

Processing fee

Online processing fee ($5.00) (Non refundable)

Late Entry Fee

Late Entry Fee ($35)

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

Credit Card *

Cardholder Firstname *

Cardholder Lastname *

Cardholder Email *

Cardholder Address *

Cardholder Address