MeCTA-Sponsored Clinic Form

Make copies of this form!  One copy is needed for EACH clinic.

Name of clinian: ________________________________________________

Date of clinic: _____________  MeCTA Membership # _____________(look on your Omnibus label)

NON-MEMBERS MUST PAY AN ADDITIONAL one-time $15  non-member fee, each year

Name of rider: ____________________________________ __Age of rider (if under 18):___________

Name of horse: ______________________________________Coggins Date: __________________

Address: _______________________________________________________________________

_______________________________________________________________________________

Phone #: ____________________________E-Mail: _____________________________________

Clinic Division: Elementary  //  Elementary/Beginner Novice  //  Beginner Novice 

Beginner Novice/Novice  //  Novice  //  Novice/Training //  Training 

Other (details): _____________________________________________________________

Jumping height: _________ Dressage level: ______________ (if applicable)

If a multi-discipline clinic, what kind of group you want to be in: ____________________________

Liability Release: I understand that this is a high risk sport and that I am participating at my own risk.  I hereby assume this risk and further do hereby release and hold harmless the organizer, organizing committee, instructors, MeCTA, their officers, agents, employees and volunteers assisting in the conduct of this MeCTA educational activity, and the owners of the property on which it is to be held, from all liability for negligence resulting in accidents, damage, injury or illness to myself, my property, including the horse(s) which I may ride.

**Signature: ____________________________________________  Date: ______________

Printed Name: ______________________________________________________

**if under 18, must have signature of parent or legal guardian.

Medical Release: If emergency medical care is required for myself or my minor child________________________ and if I, or a spouse or relative is not able to convey permission in a timely manner, then the undersigned authorizes appropriate emergency medical care as deemed necessary by emergency medical personnel, a physician or the medical facility providing treatment.  I have read this entire release and agree to it.

**Signature: ____________________________________________  Date: ______________

Printed Name: ______________________________________________________

**if under 18, must have signature of parent or legal guardian.

Please specify any NECESSARY scheduling requirements ____________________________________

___________________________________________________________________________

___________________________________________________________________________

Please send your check (payable to MeCTA) for the amount listed for the clinic (send separate check for each clinic), a copy of a negative Coggins (within 3 years) for each horse involved, and this form to the contact person listed for the clinic: (please check clinic listings for this info)

SEND THIS FORM IN THE MAIL AS SOON AS POSSIBLE; FIRST COME, FIRST SERVE.