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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

I give consent for my name, address, gender and category of membership to be provided to the HSAA Association of Queensland and am aware that my name will be given to the insurance broker. *

Do you have or have ever suffered from any illness which might affect your activities whilst at the club eg, Epilepsy, Asthma, Diabetes etc *

Yes

If yes, please provide details

Name of Preferred Vet *

Vet's phone number *

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.

Gladstone Horse Performance Club

Member Registration

Member Details

Residential Address

Mailing Address

Other information