NCR Membership Form

Northumberland County Riders' Horse Club

Membership Form 2010

Membership Categories:

Youth Membership : 17 years of age and under as of January 1st 2010.
Adult Membership : 18 years of age and over as of January 1st 2010.
Family Membership : Immediate family involved in club activities. Children MUST be single, living at home and still attending school. Self-supporting children of such families are required to pay for an Adult membership.

Please Select Membership Type: (X marks the selection)

Youth - $ 15.00 _______ Adult - $25.00________ Family - $35.00_______

After April 30, 2010 : Youth - $20.00 _____ Adult - $30.00 _________ Family - $40.00 _______

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

Participant's Name: _________________________________ Date of Birth: D / M /YEAR

Address: _________________________________________________________________________________

Postal Code: __________Telephone Number: _________ Email Address: _________________________

Horse's Name: ____________________________________

Emergency Contact Name:______________________ Telephone Number: __________________________
( Parent, Guardian: if under the age of 18 years or Person other than that listed above: if an adult)

Insurance: (OEF / Farm / Property) _________________________________________________________________________

For Office Use Only: Assigned Participant Number: ________________

If buying a family membership please list the participants below. If participant is showing more than one horse, please

list all names below for extra numbers.

Name of Participant

List all others on back of form

Birth Date

D / M / YEAR

Horse's name

Office Only No. Given

Make Cheque Payable to: Northumberland County Riders' Horse Club

Mail To: Cathy Jeschke-Colley 8348 Cavan Rd. RR#1, Gores Landing, Ontario. K0K-2E0

Email to: ncrhorseclub@eagle.ca