LANARK COUNTY WESTERN HORSE CLUB MEMBERSHIP APPLICATION
I, the undersigned, certify that I release the LANARK COUNTY WESTERN HORSE CLUB (LCWHC) from any and all jnjuries of any nature, which may be occasioned to me or my animal(s). I do undertake to indemnify the LCWHC against all claims of demand arising from any injury caused by me or my
animal(s) or occasioned by the negligence of any person(s) in charge, or any damage to the property while being used by the LCWHC and further, responsible for any damages or injury suffered by ne or my family, or dependants, to my/our person(s) or property at any evebt sponsored by the LCWHC.
PLEASE ENSURE THAT YOU HAVE OBTAINED A COPY OF THE CURRENT BY-LAWS AND UNDERSTAND THE RULES OF THE LCWHC.
I am aware that helmets ARE PERMITTED to be worn in ANY CLASS at any event by ANY RIDER, but helmets are only REQUIRED to be worn by all competitors 18 and under, Parent/Guardian may sign off a competitor under age 18 to not have to wear a helmet if desired. Please write, beside the participant's name below, your intention and initial it
Name(s) of all family members participating Signature (if over 18 years)
This form must be signed by all exhibitors listed, or parent/guardian if under 18 years
MAILING ADDRESS: please include your full address & phone # properly, it is the only way we can reach you!
STREET/RR#______________________________________________________
CITY/TOWN__________________________POSTAL CODE_________________
PHONE #_________________________EMAIL____________________________
PROOF OF MINIMUM $1,000,000 LIABILITY INSURANCE for the current show season is required to participate in any LCWHC event. A PHOTO COPY IS REQUIRED TO BE ATTACHED TO THIS MEMBERSHIP FORM. Failure to provide adequate proof of coverage will make exhibitors ineligible to participate.
INSURANCE COMPANY________________________EXPIRY DATE___________
POLICY #________________________ OEF #_________________________
MEMBERSHIP FEE:
INDIVIDUAL ($15.00) DAY ($5.00) FAMILY ($30.00)
immediate family only, Please!
OFFICE USE ONLY Membership paid by: cash cheque(driver's license required
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DATE RECEIVED AUTHORIZED BY |