Northumberland County Riders' Horse Club

                                               Membership Form 2017

Membership Categories:


Youth Membership: 17 years of age and under as of January 1st 2017.
Adult Membership: 18 years of age and over as of January 1st 2017.
Team Membership: Teams may be made up of a group of riders from the same farm etc. Each team member must have an individual membership. Team fee is $20 per team. All points collected from each rider on the team will count towards year end team award.

Please Select Membership Type: (X marks the selection)


  Youth - $ 20.00 __________                Adult - $30.00____________           Team - 20.00___________



Please note: This section must be completed in full to receive a membership and participant number.


Participant's Name:   __________________________________________________________________

Horse's Name: _______________________________________________________________________

Date of Birth:  D      / M       /YEAR

Address: ____________________________________________________________________________

Postal Code: _________________________     Telephone Number: ____________________________

Email Address: _______________________________________________________________________

Emergency Contact Name: _________________________Telephone Number:  __________________

( Parent, Guardian: if under the age of 18 years or Person other than that listed above: if an adult)

(OEF / Farm / Property)  ____________________________________________________________________________

Please remember that your membership is valid from


Do you wish to be on the Northumberland County Riders’ Horse Club email list and receive club updates, newsletters, minutes of meetings etc.?

Yes  _____________         No_____________


Do you give permission to have your name(s) displayed in  the Northumberland County Riders’ Horse Club show results , newsletters, minutes ect. posted on the website?

Yes   ______________      No___________­­__

For Office Use Only: Assigned Participant Number: ________________


      Make Cheque Payable to: Northumberland County Riders' Horse Club

      Mail To:  Ashley Irvine 283 Packer RD Roseneat, Ont. K0K 2X0

      Email to:





     If you are buying a team membership, please list the participants and the two classes

     the participant will collect their points in below.
     If participant is showing more than one horse, please list all names below for extra numbers. 



       Name of Participant /Classes





















Birth Date


D   / M   / YEAR

D   / M   / YEAR


D   / M   / YEAR


D   / M   / YEAR

Horse's name








Office Only No. Given