2025 VBHSA Membership

Type of membership. Check all that apply:*

IndividualIndividual (Lifetime)LesseeFarm/BusinessFarm/Business (Lifetime)
Name *
If using Farm or Business Name, please incl Contact name in parenthesis
Age Level*

Child (12 and under) Year of birth is requiredJunior (13-17) Year of birth is requiredAdult (18 and Over)
Birth date (Only if 17 and younger)
Only if 17 and younger
Barn Name
Address*

Street Address Line 2
Email*
Phone*
Certification of Information
My e-signature below indicates that I certify that the information as completed on this form is true.
E-Signature*
Fees
Select Membership Type(s)*
prevnext( X )
Individual Membership$60.00

Individual Lifetime Membership$300.00

Lessee Membership $60.00

Farm/Business Membership$40.00

Farm/Business Lifetime Membership$150.00

Subtotal $0.00Tax $0.00Total $0.00
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