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Membership Category:*

Member Details

Title:

First Name:*

Last Name:*

Date Of Birth:

Sex:

Email:*

Alternate Email1:

Alternate Email2:

Residential Address

Address:*

Suburb:*

Country:

State:*

Post Code:*

Home Phone:

Mobile:*

Mailing Address

Address:

Suburb:

Country:

State:

Post Code:

Work Phone: Ext:

Fax No.:

Other information

PIC Number:*

Emergency Contact:

Name:*

Relationship to Rider:*

Contact Number:*

Have you any conditions / ailments the club should be aware of? Are you taking any medication we should be aware of?:

Yes

If yes, please provide details::

Do you hold a current First Aid Certificate? :

Yes

Do you consent to your image being used on the club website, Facebook page and other promotional materials? (If this is not ticked, we will assume Yes) :

Yes

Yorke Peninsula Equestrian Club Inc

Member Registration

Member Details

Residential Address

Mailing Address

Other information