Northumberland County Riders' Horse Club

                  Membership Form 2011

Membership Categories:

Youth Membership : 17 years of age and under as of January 1st 2011.
Adult Membership : 18 years of age and over as of January 1st  2011.
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, 2011 : 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:   __________________________________________________________________

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)

Insurance: (OEF / Farm / Property)  ____________________________________________________________________________

Please remember that your membership is valid from

November 1 to October 31 each year.

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

Email to: ncrhorseclub@eagle.ca

If you are 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

Birth Date  D   / M   / YEAR D   / M   / YEAR D   / M   / YEAR

Horse's name

Office Only No. Given