Mega Rating Entry Form
Directions: Fill in form and then save as:
Memberlastname Firstname.doc (or .rtf)
Example: Smith John.doc
Then email to: firstname.lastname@example.org
Candidate for Rating Level: Select If applicable – 2nd rating: Select
Member Last Name: First Name:
Current Rating Level: Select
Phone #: Email address:
Home or cell
Activity Release Form on file with Oregon
Club Name: Select Region for 2011:
D3 Classic $70.00, C1 Classic $80.00, C2 Classic $90.00. A single portion of a rating is $30.00.
No entries will be accepted after the July 8th deadline. This includes incomplete entries received.
Special needs or information to share:
D3, C1, C2 HM $ Select
D3, C1, C2 Flat $ Select Mail club or personal checks payable to ORPC
D3, C1, C2 Jump $ Select to: Stacy Emerson
D3, C1, C2 HM/Flat $ Select Mega Rating
D3, C1, C2 Flat/Jump $ Select 19580 SW 48th Ave
Tualatin, OR 97062
D3 Classic $ Select
C1 Classic $ Select
C2 Classic $ Select
Facility Use Fee $25.00
Pay online via Regional Website using PayPal
Total: $ oregon.ponyclub.org
Candidate Signature: Date:
Parent Signature: Date:
DC Signature: Date:
D.C. signature certifies Candidate is appropriately prepared for test and in good standing with club.
By checking this box, you agree that the typed signature(s) above constitutes the same as signing this document.