Southeastern New England Region

USPC

WORK STUDY PROGRAM

Candidate Application

C2, C3, B, H/HA, A

The following information is held in strict confidence and is available only to the Program Coordinator, VRS's & RS. Candidates' applications will not be considered nor will they be reimbursed until all forms are returned to the Program Coordinator.

Please attach a one page, typed letter covering your Pony Club qualifications, experience, and club commitment.

Candidate's Name: Present Rating:

Candidate's Phone: Pony Club:

DC's Name:

Address:

City: State: Zip:

Phone : E-mail:

Please fill in the rating level you feel qualified to instruct or assist. Place an * by any activities where you feel you are particularly well qualified.

Rallies:

Games to _____Level Tetrathalon to _____Level

Show Jumping to _____Level Dressage to _____Level

Know-Down to _____Level Polocrosse to _____Level

Vaulting to _____Level Combined Train. to _____Level

Horse Manag. to _____Level

Clinics:

Bandaging to _____Level Conformation _____Level

Longeing to _____Level Conditioning to _____Level

Lameness to _____Level Feeds & Feeding to _____Level

Ratings Prep to _____Level Mock Rally to _____Level

Date of latest Standards Clinic you have attended: ________________________

Please rate yourself on the following qualities:

	Great	Good	Needs Work		Great	Good	Needs Work
Enthusiastic				Safety Awareness
Responsible				Respected by Peers
Decisive				Flexible
Mature				Common Sense
Well-Mannered				Dealing w/ Adults
Articulate				Leadership Abilities
Tactful				Innovative
Honest				Takes Initiative when needed

I, of Pony Club,

certify that to the best of my knowledge, the above information is correct.

Signature Date

Please complete this form and return it to:

Debbie Stewart

60 Warren Street.

Plainville, MA 02762

Phone & Fax: (508) 695-3904 E-Mail: dstewart@jpstewart.com