Southern Cross Western Performance Club

Member Registration

Member Details

Residential Address

Mailing Address

Ext.

Other information

Are you a financial member of Australian Reined Cow Horse Association? *
If yes, please provide your membership number
BREED/COLOUR SOCIETY MEMBERSHIP INFORMATION Please list Membership Details for any of the following (if applicable)
AQHA MEMBERSHIP
ASH MEMBERSHIP
PHAA MEMBERSHIP
Other Recognised Breed/Colour Society Membership
MEDICAL INFORMATION & CONSENT
Doctors Name
Medical Centre *
Phone
As far as you are aware, are you allergic to any drugs/foods?
Are you taking any regular medication? If so, for what reason?
Do you have any long term illnesses (e.g. Epilepsy, Asthma, Diabetes)
PHOTOGRAPHY / IMAGE USE CONSENT
I am aware that there maybe times that photographs and/or video footage maybe taken during club activities by approved agents and/or officers of the society.
Such images/video shall only be used for society purposes in accordance with the Safeguard and Protection U18’s Policy and I give consent for myself (son/ daughter) to feature in such photos/ images.
I hereby only grant approved agents the right to use the images resulting from the photo/video.
This includes any reproductions or adaptations of the images for all general purposes i.e. local newspapers, local magazines, other community promotional articles (inc. flyers) and the Club’s website.
I give consent for myself (son/ daughter) to feature in such photos/ images *
VETERINARY EMERGENCY
In the unlikely event of an accident where your horse is severely injured and in need of emergency veterinary attention, the Southern Cross Western Horse Association strongly recommends you provide your consent to calling veterinary assistance. Note that you will be responsible for all costs incurred.
Declaration: In the event of an accident, where I am injured and unable to do so, I hereby give my authorisation for an authorised representative of the Southern Cross Western Horse Association to call for veterinary assistance in the event that the horse is severely injured and in need of emergency veterinary attention. *
ADDITIONAL INFORMATION Please add any additional relevant information:

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?

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