Membership Registration Form
MEMBERSHIP REGISTRATION FORM (club members, Judges and Instructors to complete – Club officials to update or enter information into MYclub, or forward to State Secretary )
Member’s Personal Details
Pony Club:
Mr / Mrs / Miss / Ms/ Other: Full Name:
Address:
Surburb/Town: Postcode:
Phone (H): ………………….. Phone (W): …………(M)……………………(fax)………………….
Email: ……………………………………..D.O.B……………………………..Age……………………………….
Occupation:………………………… Ever attended a Pony Club other than the one listed above o Yes o No If Yes , which club…………………...…………………..
What year did you join Pony Club………………………..
Certificates held: (please insert year passed) D D* C K
C* B H A
Pony Club Association of Tasmania Inc
M_Membership Registration Form - Generic2
Membership Registration Form
Membership Type:
Age taken at 1st January
o Riding Member (please specify)
o Junior (Under 17years)
o Associate (17-25years)
o Adult Riding Member
o Non-Riding Member
o Club Instructor
o Volunteer
Instructor Details
o PC O Level date
o PC Level 1 date………………………………
o EFA Qualification date
Judging Details ……………………………
Dressage…………………what grade………….
Show jumping……………P/C EFA (please circle)
Technical Delegate…………………………..
Course Designers SJ XC
FIRST AID Qualification
Pony Club Association of Tasmania Inc
M_Membership Registration Form - Generic2
Membership Registration Form
First Aid Certificate:…………….….Providers Name………………………………….…….Number……………
First Aid Expiry Date:…………………………………….
Member Declaration (to be signed by new members)
I agree to abide by the rules, code of conduct regulations, policies, procedures and directives as stipulated by Pony Club Association of Tasmania Competition rules and affiliated bodies.
I acknowledge that horse sport is dangerous and that accidents causing death, bodily injury, disability and property damage can, and do happen.
I acknowledge and agree that neither PCAT nor “the organizers” shall be under any liability for death, or bodily injury, loss or damage which may be sustained or incurred by the applicant, as a result of participation in or being present at PCAT endorsed events, except in regard to any rights I may have arising under the Trade Practices Act 1974.
I acknowledge that I have read and understood the information provided in this membership form regarding codes of conduct and privacy.
Signed: Date:
Member’s Parent/Guardian Declaration
Release of Instructor/Judges Details
I consent to being listed on the PCAT Registered Instructor’s/Judges List, which will be made available to Club Personnel only. Personal details will include First Name, Second Name, Contact details including Postal address, phone number, email and Coaching Qualifications
Signed……………………………………………………...Date…………….
I do/or I do not consent (please circle) to my personal details being advertised to the public verbally, in printed or electronic mediums. Personal details will include First Name, Second Name, Coaching Qualifications and Contact Number.
Signed……………………….. ……………..Date………….
Voluntary Workers Personal Details – to be completed by volunteer workers, new member’s parents or siblings – Club officials to update MyClub or forward to State Secretary. Judges and Instructors to complete Member Registration Form only
Pony Club:
Mr / Mrs / Miss / Ms/ Other: Full Name:
Address:
Surburb/Town: Postcode:
Phone (H): …………………… Phone (W): …………..…Phone (M):
Email:
Pony Club:
Mr / Mrs / Miss / Ms/ Other: Full Name:
Address:
Surburb/Town: Postcode:
Phone (H): …………………… Phone (W): …………..…Phone (M):
Email:
Pony Club:
Mr / Mrs / Miss / Ms/ Other: Full Name:
Address:
Surburb/Town: Postcode:
Phone (H): …………………… Phone (W): …………..…Phone (M):
Email:
Pony Club Association of Tasmania
M_Membership Registration Form - Generic2