Friends & Family Partner name (if applicable) _______________________ ________________ Dancing Horse Hill | | Eventing Derby | | July 25 2015 | | | | ENTRY FORM |_______________| RIDER NAME _________________________________________________________________ ADDRESS ______________________________________________________________ City _____________________________ State________________ Zip _______ PHONE __________________________ EMAIL _______________________________ EMERGENCY CONTACT __________________________ PHONE ___________________ HORSE NAME _______________________________ OWNER __________________________ NAME ON COGGINS (if different from show name) _______________________ MORNING COMPETITION LEVEL ____________________________________________________________________ AFTERNOON COMPETITION LEVEL (to be filled out by show secretary) ____________________________________________________________________ COMPETITION FEE ____________ STABLING (check with organizer for availability) ____________ TOTAL FEES: ____________ ORGANIZER Robin Crickman 7115-639-2641 robin@newsguy.com Dancing Horse Hill, N6512 110th Street, Elmwood, WI 54740 INSTRUCTIONS: One entry form for each horse-rider combination If entering same combination more than once (four rounds), complete two entry forms and mark at top ENTRY 1 and ENTRY 2. Mail the following four items to the organizer (1)Entry form (2)Photocopy of EIA (coggins) Test (3)Check or money order payable to Dancing Horse Hill (4)Signed release of liability Entries must be postmarked by July 17, 2015 or late fee applies.