THE HORSE-A-RAMA CLUB
Elizabethtown, Brockville, Ontario
The Horse-A-Rama Club
Presented by Elizabethtown Harness Horsemen’s Association (E.H.H.A.)
ONTARIO INC. 000569627
2009 Membership Application Form
I, the undersigned, certify that I understand and accept that there is a high element of
risk involved in horse activities, and I release the The Horse-A-Rama Club (E.H.H.A.)
and all of its representatives from any bodily injuries or death to participants and horses,
losses, damaged or stolen properties that may arise during events held by
The Horse-A-Rama Club (E.H.H.A.). I give up any right to claim liability against the
The Horse-A-Rama Club (E.H.H.A.)and all of its representatives, for any damages,
losses or injuries however arising or caused.
I am aware that certified horseback riding helmets are permitted and
recommended to be worn in any class by any rider.
SINGLE MEMBERSHIP:
Name:________________________________________
Age(If under 18):_________________
MailingAddress:_______________________________________________________________
City:_________________________________________________
Postal Code___________________
Telephone Number:___________________________________
THIS FORM MUST BE SIGNED BY COMPETITORS OVER THE AGE OF 18,
OR BY THEIR LEGAL GUARDIAN IF THEY ARE UNDER THE AGE OF 18.
AuthorizedSignature:___________________________________
Printed Name:__________________________
FAMILY MEMBERSHIP
Name of family members participating and age (as of January 1st, 2009)
for every applicant under 18 years of age.
1)________________________________________________ Age:_____________
2)_________________________________________________ Age:_____________
3)_________________________________________________ Age:_______________
4)________________________________________________ Age
5)_________________________________________________ Age:______________
Name:____________________________________________________________________
Mailing Address:____________________________________________________________
City: ____________________________________________
Postal Code__________
Telephone Number:________________________________
e-mail address:_____________________________________
COMPETITORS MUST SIGN THIS FORM OVER THE AGE OF 18, OR
BY THEIR LEGAL GUARDIAN IF THEYARE UNDER THE AGE OF 18.
AuthorizedSignature:___________________________________
Printed Name:_______________
VALID LIABILITY INSURANCE for 2009 is MANDATORY and REQUIRED to exhibit
horses at any The Horse-A-Rama Club (E.H.H.A.) event.
Please complete the following information:
InsuranceCompanyName:__________________________________________________
Policy Number:____________________________________
ExpiryDate: ____________________
MEMBERSHIP FEEs Before May 1st: MEMBERSHIP FEES AFTER MAY 1ST
DAY: $7 DAY: $7.00
YOUTH: $12.00 YOUTH: $17.00
SINGLE: $15.00 SINGLE: $20.00
FAMILY: $25.00 FAMILY: $30.00
Method of payment: Cash________
Cheque________ (Make cheque payable to E.H.H.A.)
Date Received:_________________________ Received By_________________________________
Membership forms will be sent out with January's newsletter!
Consent Form:
The Horse-A-Rama Club
Elizabethtown Harness Horsemen’s Association
(Ontario Inc. #000569627)
We, at The Horse-A-Rama Club are very proud of our members and their
achievements. We like to recognize their success by including their photos,
names and horses names on The Horse-A-Rama Club’s web site, newsletters
in local media and so on.
In order to do this, we require your consent. This consent is required to comply
with theprovisions of the Municipal Freedom of Information and Protection of
Privacy Act and shall be placed in our Secretary’s files and will remain valid unless
cancelled in writing.
Please complete the form below and return it only to a Horse-A-Rama Club Director.
I, _________________________________________( ) grant permission
( ) do not grant permission
to The Horse-A-Rama Club to display photographs and/or achievements of the
person’s listed below
1. ______________________________ 2._________________________
3. ______________________________ 4.__________________________
5. ______________________________ 6. __________________________
along with their name and horse’s name in The Horse-A-Rama’s club newsletters,
web site, news and sports, in the local media and advertising.
___________________ ______________________________________
Date Signature
Signature of Parent/Guardian if under 18 years of age
