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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

Are you an Equestrian Australia/Equestrian Tasmania Member *	YesNo
If yes, are you an Equestrian Australia/Equestrian Tasmania Competitor *	YesNo
If yes, are you an Equestrian Australia/Equestrian Tasmania Participant *	YesNo
In Case of Accident Name of Contact *
In Case of Accident Relationship of Contact *
In Case of Accident Mobile # of Contact *
Is your horse registered with Equestrian Australia/Equestrian Tasmania? *	YesNo

Notes

NOTE:
Family membership consists of two parents/guardians (senior riders) and thier one/two children (junior riders)
Please ensure that all names and DOB's are provided for junior family riders.

For membership enquires please contact Secretary Abby via email sjtnorth@gmail.com or phone 0439 966 174

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.

Jumping Tasmania North

Member Registration

Member Details

Residential Address

Mailing Address

Other information

Notes