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Event Date:
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Name:
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Rider's DOB:
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Are you entering Horse Trial, combined test, or
individual dressage, stadium or xc or any phase as
an extra.
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Level: Intro, Starter, BN,N
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Division: Horse/Rider/Open:
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Address.
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City, State, Zip
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Phone
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Email.
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Cell Phone
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Horse's Name:
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Breed:
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Color:
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Age:
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Height:
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Name on
Coggins:
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Horse Owner:
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______________________________________________________________________________________________________
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Are you riding a 2nd horse:
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2nd Horse's Name and Division:
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_________________________________________________________________________________________________________
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Horse Trial: $75 Starter, BN, N ($60 Intro)
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HT Level:
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HT Dressage Test A or B
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HT Stadium Level:
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HT XC Level.
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_________________________________________________________________________________________________________
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Combined Test: $50
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CT Level:
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CT Dressage Test A or B:
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CT Stadium Height:
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_________________________________________________________________________________________________________
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Dressage by itself if not riding HT or CT.
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Walk/TrotUSDF Intro A 2011
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2010 USEF BN - A
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2010 USEF BN - B
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2010 USEF N - A
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2010 USEF N - B
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Name of 1st dressage test.
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Name of additional dressage test(s).
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_________________________________________________________________________________________________________
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Stadium by itself if not riding HT or CT:
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Intro 18"; Starter 2' 0"; Beginner Novice 2' 7"; Novice 2' 11"
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1st Stadium. Height.
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Add'l round(s) Height.
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_________________________________________________________________________________________________________
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Cross Country by itself if not riding HT or CT:
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Intro 18"; Starter 2' 0"; Beginner Novice 2' 7"; Novice 2' 11"
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1st xc. Level.
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Add'l xc round(s) Level.
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_________________________________________________________________________________________________________
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Extras:
Would you like to do anything extra? Please tell us what you would like to do.
Name of Dressage Test, Stadium Height, or Level of XC.
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_________________________________________________________________________________________________________
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Entry Fees:
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Entry Fee for Horse Trial: [$75 ($60 Intro)]
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Entry Fee for Combined Test: ($50):
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Additional Dressage Tests: ($20 each)
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Additional Stadium: ($10 each)
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Additional XC: ($20 each)
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Entry Fees for individual phases:
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1st dressage if not doing HT or CT($25)
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1st stadium round if not doing HT or CT($15)
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1st xc round if not doing HT ($35)
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Total:
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Are you an ESDCTA member ?
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If yes, are you riding for year end awards?
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_________________________________________________________________________________________________________
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Rider's Highest Level (past 2 years):
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Horse's Highest Level (past 2 years):
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_________________________________________________________________________________________________________
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Emergency Contact:
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Relationship of Emergency Contact:
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Phone:
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Is your emergency contact accompanying you to Burgundy Hollow?
If not, please provide name and cell # of someone we may contact during the event:
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Questions, comments, feedback:
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Enter online, press Submit or Enter.
Please be sure you get the confirmation page.
Next:
Mail Coggins, signed release and check to:
Burgundy Hollow Farm, Inc.
c/o Michelle Casale
204 Bellis Court
Stroudsburg, PA 18360
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