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Membership Category*

Member Details

Title

First Name*

Last Name*

Date Of Birth*

Sex

Email*

Alternate Email1

Alternate Email2

Residential Address

Address*

Suburb*

Country

State*

Post Code*

Home Phone

Mobile*

Mailing Address

Address*

Suburb*

Country

State*

Post Code*

Work Phone Ext.

Fax No.

Other information

HRCAV Number

EA Number

PIC Number

Do you have ambulance cover? *

Yes

Do you have a current first aid certificate? *

Yes

If yes please include Certificate Number and Expiry Date

May we publish your name in Club results and photographs of you in any media publication? *

Yes

Email address is already assigned to a member,
please use an alternative email address.

You appear to be an existing member.
Do you want to renew your membership?

Primary Member must be an Adult/18+. Children/under 18 memberships can be added on the next page.

Aged pension membership is for members over 65 years.
Please choose another membership type or correct your date of birth.

EA number does not match member name.

To be eligible for this membership, a doctors certificate/para classification/RDA associate membership must be provided to the club to receive a code to apply for this membership type. Please type code in below.

Mid South East Dressage Club Incorporated

Member Registration

Member Details

Residential Address

Mailing Address

Other information