G & Hea Adult Riding Division

2018 MEMBERSHIP ENROLMENT FORM

NAME ADDRESS CONTACT Tel No MOBILE No EMAIL FACE BOOK NAME EWA member no: Basic ARCA Type of EWA membership: (if applicable) Competitor Participant

PLEASE SELECT MEMBERSHIP TYPE: Type Fee Tick Full $170 Associate $120 $310 (2 members) Family $150 (per additional person) Social $20 Amount Paid: $ Date of transfer: EFT Receipt number: Please insert your Surname-Membership as the payment

reference when transacting your payment. I hereby apply to become a member of the Gidgegannup Equestrian Association and confirm that I have read and understand the terms and conditions as outlined in the GEA information pack. I declare that I am 18 years of age or over. I have signed that EWA waiver form. Signature of Member: Date:

EMERGENCY CONTACT AND MEDICAL INFORMATION (STRICTLY CONFIDENTIAL) Emergency Contact Contact Ph No 1. Name 1: Emergency Contact Contact Ph No 2. Name 2: Riders Medical Condition(s) & Regular Medications: Allergies:

(please specify) Date of Birth: Medicare Number: Private Ambulance Insurance? Yes No

MEMBERSHIP FEES ARE NON-REFUNDABLE

Payment Details OFFICE USE Membership forms and Payment can be returned to: Full: $ Family: $ Other member/s: [email protected] or Associate: $ Gidgegannup Equestrian Association Inc Social: $

PO Box 77 Gidgegannup WA 6083 or TOTAL FEES PAID: $ EFT: Cash: Cheque: EFT details BSB: 633-000 ACCOUNT No: 150137297 DATE: ACCOUNT NAME: GIDGEGANNUP EQUESTRIAN ASSOC INC RECEIVED BY: Cheques/money orders payable to Gidgegannup Equestrian Assoc 2018 RIDER/HORSE INFORMATION FORM

RIDER’S NAME:

RIDER’S EXPERIENCE (tick as many boxes as applicable): Green/ Walk/Trot/ Walk/Trot Pony club ARC Inexperienced Canter Preparatory Elementary & Dressage Level: (If Prelim Novice applicable) above Show jumping: (If Beginner 50-60cm 60-75cm 80+cm applicable): (under 50cm) Games/ Western Natural Eventing Endurance agility Riding Horsemanship

Other:

HORSE’S NAME 1: AGE:

HORSE’S EXPERIENCE (tick as many boxes as applicable): Green/ Walk/Trot/ Pony club ARC Inexperienced Walk/Trot Canter Prep Elementary & Dressage Level: (If Prelim Novice applicable) (or nil) above Show jumping: (If Beginner 50-60cm applicable): (under 50cm) 60-75cm 80+cm Games/ Western Natural Eventing Endurance agility Riding Horsemanship

Other:

HORSE’S NAME 2: AGE:

Green/ Walk/Trot/ Pony club ARC Inexperienced Walk/Trot Canter Prep Elementary & Dressage Level: (If Prelim Novice applicable) (or nil) above Show jumping: (If Beginner 50-60cm applicable): (under 50cm) 60-75cm 80+cm Games/ Western Natural Eventing Endurance agility Riding Horsemanship

Other:

ANY OTHER INFORMATION YOU CONSIDER RELEVENT TO PLACE HORSE AND RIDER IN THE APPROPRIATE GROUPS: (e.g. horse has never cantered in a group)