Kumeu Western Riding Club
MEMBERSHIP FORM 1 June to 31 May
APPLICATION DETAILS
MEMBERSHIP TYPE
*
Family $70
Riding $50
Youth $25
Social $20
NAMES
(For family membership please list all family names - max 2 adults & 2 children)
Primary Adult Name
*
First Name
Last Name
Adult Name
First Name
Last Name
Youth Name
First Name
Last Name
Please Select
Junior (13 yrs & under)
Senior (14-18 yrs)
Youth Name
First Name
Last Name
Please Select
Junior (13 yrs & under)
Senior (14-18 yrs)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Second Family members Email
example@example.com
Phone/Mobile
*
-
Area Code
Phone Number
Add my name to the Facebook Messenger chat group? (Financial member KWRC Communication only)
*
Yes
No
Emergency Contact
*
First Name
Last Name
Relationship
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone/Mobile
*
-
Area Code
Phone Number
Any existing medical conditions we should know about
*
Do you have any objection to your name/photo being posted on our Facebook page or website
*
No
Yes
PAYMENT METHOD
*
Cash (must be handed to a committee member only)
Direct Debit ANZ - 06 0153 0069885 00 (use your name and subs as reference)
Signature:
Dated
*
/
Year
/
Month
Day
Date
I/We hereby agree to abide by the Constitution and Rules/Regulations of the Kumeu Western Riding Club, as available from the Committee at kwrc.nz@gmail.com.
*
(For youth membership only this form must be signed by a parent or guardian)
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