Northumberland County Riders Horse Club
Membership Form 2008
Membership Categories:
Youth Membership : 17 years of age and under as of January 1st 2008.
Adult Membership : 18 years of age and over as of January 1st  2008.
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, 2008 :   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)

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

D   / M   / YEAR

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