HARMONY EQUESTRIAN CLUB INC.

Membership Application Form:

Full name:

Residential Address:

Suburb: Postcode:

Telephone number (please include at least two):

Mobile: AH: BH:

Email:

Postal address (if difference from above):

Suburb: Postcode:

HRCAV Card Number (N/a for new members):

Type of HRCAV membership: Senior: Junior: Associate:

HRCAV highest level: 1 or above: 2 3 4 5

Riding years of experience:

Other equestrian clubs or interests (previous or current):

Horses name:
NOTE: Members who are between 16 - 18 years must have a parent or guardian accompanying them at rallies.
Payment Details (complete either Cheque or direct deposit details)

Cheque number: Direct deposit reference:

(Cheque or Bank Deposit to Harmony Equestrian Club: BSB 633000 Acc 156067498 )
Please use your name as a reference & send an email confirmation to the secretary & treasurer

Membership fee: Senior $190 Junior (U18) $115 Non-riding $60 Associate $75

Chaff Chat subscription required? $57 for 12 months Yes No

Total amount paid:

Privacy Legislation HRCAV Member Approval

Are you happy for the HRCAV to supply your name and address details to any club, HRCAV or EFA sponsors?

Yes No

Signed: Date:
(Members aged under 18 years must have a parent/guardian sign the form in addition to the rider)

The Club or its Committee or persons acting on their behalf shall not be held responsible for any accident or injury to
any person or property however caused.
 First Aid Information (HEC)

Full name:

Date of birth:

Sex: Next of kin:

Two telephone numbers in case of an emergency:

1. 2.

In the event of (The member)

requiring medical attention and treatment whilst at Harmony Equestrian Club Inc., or at an outside event, I authorise
the Harmony Equestrian Club Inc. to obtain all the necessary medical assistance or treatment, to engage as my agent
any doctor, nursing assistance or hospital accommodation, with expenses incurred to be met by me. I further
authorise the use of anaesthetic by a qualified medical practitioner if in his/her judgement this is necessary. Without
limiting the above, I appoint the Harmony Equestrian Club Inc. to act as my agent with full authority to do any act,
matter or thing on my behalf (including signing any hospital or medical form on my behalf) in respect of myself whilst I
am at or near the Riding Club Ground.

Signature Of Member: Date:

(Members aged under 18 years must have a parent/guardian sign the form in addition to the rider)

Please supply the following information:

1. Any physical limitations or medical conditions? (E.g. Asthma)

2. Any other relevant information concerning yourself? (E.g. Fainting, nose bleeds, long term therapy)

3. Any allergies you have? (E.g. Bee stings, penicillin) Please include any anaesthetic allergies

4. Have you had full Tetanus immunisation, if so when:

5. Medicare Number:

6. Medical Benefits Insurance (fund & number):

7. Ambulance Cover: Yes No

8. Family Doctor Name:

Phone number: