Wellington Junior/Young Rider Clinic
Print out and send in

Riders fees: $550 all inclusive fee. Catered Lunch available for purchase. Saturday the Challenge of the Americas Breast Cancer Quadrille, dinner and dancing with the stars Sunday evening.

Please send applications and checks to:

Dr. Cetty Weiss
11924 West Forest Hill Blvd.
Suite 13
Wellington, Fl. 33414
561-282-7495

All riders must wear helmets

Rider Application

Name___________________________________________ age_________

Address ___________________________________

City/state/zip_______________________________

Phone__________________________ cell__________________________

E-Mail: (print clearly) __________________________________________

Emergency contact____________________________________________

Emergency phone #_________________________

Trainer’s home______________________________

Trainer’s phone #_______________________e-Mail: ________________

Horse’s name_____________________ Breed_______________________

color_________ Age_____ Height__________ Sex_________

Highest level shown_______________________

Coggins: send copy

Very important - shirt size_________________
(Ladies sizes)

We will try to match rider with preferred trainer if possible. Indicate who you would like to ride with. We will accommodate you as much as possible.

Ann Gribbons Steffen Petersl

Stabling available off premises if necessary. (There is a fee) This is available only to riders not already in the Wellington area.

Please check if you need stabling ___________

Please list any medical conditions that we should know about.

Waiver of Liability

I understand that by participating in the JR/YR rider clinic, I do so at my own risk, and the risk of the horse named below. I understand that volunteers, the equestrian facility and anyone acting in their behalf are not responsible for accident, damage, injury, theft or illness to the horse, riders and spectators or any other person in connection with this clinic. To include Dr. Cetty Weiss and the Weiss Family Chiropractic Center, Mrs. Carol Cohen and Two Swans Farm. By signing this form I agree.

Rider’s signature____________________________________________

Parent/guardian signature____________________________________

Horse owner’s signature______________________________________

Print clearly name of horse and rider

Please give me your address where you will be at the end of February.

Name:_________________________________________________

City/state/zip___________________________________________

Phone#_________________________________________________