Membership Application and Renewal

Membership Application and Renewal
First Name*
(or Organization name)
Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry
Mobile Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Birthday

MonthDayYear
Date
Referred by
Please select your communication preferences below*

Yes, add me to Gaggle group!Sign up for Highline newsletterNot interested
What are you interested in?*

Trail ProjectsPublic AffairsFundraisingSocial ridesProgramsVolunteeringEducationClinicsOther
WARNING AND RELEASE! Under Colorado law, an equine professional is not liable for an injury or the death of a participant in equine activities resulting from the inherent risks of equine activities, pursuant to section 13-21-119, Colorado Revised Statue. I (We) release the Four Corners Back Country Horsemen, also known as 4CBCH, it's officers, directors and agents of any an all liability which may arise as a result of injury to my (our) person or property that may be sustained in connection with the chapter's activities.*

I agree
Membership start (Valid for 12 months)*

MonthDayYear
You will receive an email from us 12 months from this date reminding of renewal
Please print your name to sign this form*
Please indicate*

New MembershipRenewal
NOTE:

Membership options and prices will display as soon as you select 'Credit Card' or 'Check' payment option below
Payment options*

Credit CardCheck
Membership options*

Individual [ $40]Membership Chapters [ $30 ]Family [ $50 ]Associate [ $45 ]
ATTENTION!! BEFORE YOU CLICK 'SUBMIT' BELOW. If you selected to pay by Check,

please mail a check to: 4CBCH at PO Box 3521 - Durango, CO 81302

Membership options *

IndividualFor single member

$30.00 Quantity
Item subtotal:$0.00

FamilyFor multiple family members

$40.00 Quantity
Item subtotal:$0.00

Membership ChaptersFor current member of another BCH chapter only

$20.00 Quantity
Item subtotal:$0.00

AssociateFor Business and Organizations only

$35.00 Quantity
Item subtotal:$0.00

Enter coupon

Total

$0.00

Spouse name
* Provide if choosing 'Family' membership
Spouse email
* Provide if choosing 'Family' membership

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: