POLOCROSSE CALGARY APRIL 2016 DORI JOHNSON CLINIC APPLICATION

This form must be filled out by EACH participant

Name:

D. O. B:

Phone:

AEF: Number:

Address:
Emergency Contact:

Relation:

Rider Experience (Please circle) BEGINNER NOVICE INTERMEDIATE

ADVANCED

Horse Experience (Please circle) GREEN INTERMEDIATE WELL TRAINED

All participants must complete a waiver form. For participants under the age of majority,
a parents permission form as well as waiver form is required to participate in the
clinic.

Meals are not included in clinic costs.

In the case of an emergency, we will, if required contact medic al help outside of our
means (ambulance). Polocrosse Calgary is not responsible for costs and fees associated
with said medical help.

All fees are non-refundable

Signature:

Date: