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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

PIC Number *

Emergency Contact

Name *

Relationship to Rider *

Contact Number *

Have you any conditions / ailments the club should be aware of? Are you taking any medication we should be aware of?

Yes

If yes, please provide details:

Do you hold a current First Aid Certificate?

Yes

Do you consent to your image being used on the club website, Facebook page and other promotional materials? (If this is not ticked, we will assume Yes)

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.

Yorke Peninsula Equestrian Club Inc

Member Registration

Member Details

Residential Address

Mailing Address

Other information