Becky Douglas Holder Clinic

CLINIC:_______________________________________Date:____________________

Rider_____________________Age___ Horse________________________________

Address_______________________________________________________________
City________________________ State________________ Zip___________________

Day Phone_____________________ E-mail_________________________________
Night phone_____________________Cell phone____________________________
Highest Eventing level rider has completed:_____________________________
Highest Eventing level horse has completed:____________________________
Pony Club rating, if applicable:_________________________________________
Please circle choice of level: Beg-Novice Novice Training
Preliminary Prelim/Intermediate
Special Requests_______________________________________________________
Included with form: ___ $375 clinic fee to Dunkerton Farms
___ $ 25/night—for those who wish to stable; no bedding provided – to Waredaca
--- $60 Semi-private (1 hr.), Friday, see info
___ $75 Private (45 min.), Friday, see info
___ Completed registration form with signature
___ Negative Coggins within 12 months
___ USEA educational activity Medical Release
No refunds unless spot filled.
Send to: Dunkerton Farms, 367 Hebron Centerville Rd., Soso, MS 39480 Phone:(601)763-3600 or (601)498-3325 E-mail:rdunkerton@bayspringstel.net

Cancellation policy: I understand the clinic fee of $375 is non-refundable. I am purchasing a time slot which is paid in advance. If I am unable to use this space I am responsible for finding another rider to fill it. A waiting list will be maintained for unforeseen circumstances but there is no guarantee.

Signature:____________________________(parent signature if rider under 18 years )