1. Mount Barker Adult Riding Club Inc (MBARC) Membership Application Form Name: ____________________________________ Address: __________________________________ __________________________Postcode: _______ Mobile No: _________________________________ Other Phone No: ____________________________ Email : ____________________________________ (please contact Secretary if you do not have access to email) PIC No: ___________________________________ (mandatory) Date of Birth: _____________________ Equestrian SA Membership No. ___________________ Membership type: Riding _____________ Non-Riding _____________ Total: $________________ (Payment can be made by cash, cheque or EFT (BSB 105-900, Account 171762940, Mt Barker Adult Riding Club). If using EFT, please put your surname as the bank reference and include a copy of your internet transfer receipt as proof of payment.) Medical & veterinary details (who should we contact in an emergency?): Contact name: ________________________ Relationship _________________Phone No: _____________ Doctor’s name: __________________________________________ Phone No: _______________________ Do you have any medical conditions we should be aware of?(please circle)………………………………Yes/No If “yes”, please specify: ____________________________________________________________________ Vet’s name: _____________________________________________ Phone No: _______________________ (all attempts will be made to contact your preferred vet on your behalf in an emergency. If we are unable to contact your vet, we will then arrange for the first available veterinary surgeon to attend to your horse) Insurance: MBARC’s EA affiliation insurance covers members for Public Liability only at club activities. For personal injury and ambulance cover, members are encouraged to join EA (24/7 personal accident coverage), and Ambulance SA. Club Communications: MBARC has a separate email group for those members who would like to receive information via email on instructors/events/clinics/product information from outside the club. Would you like to receive this additional information via email? (please circle)................................... Yes/No Membership is not valid until approved by the committee. Please ensure you are familiar with the MBARC Handbook and the MBARC Safety Booklet, as you agree to all club rules contained therein on signing this membership application. Please be aware that as a member of MBARC, you accept that pictures of you and your horse may be uploaded to the MBARC website or Facebook page. Membership Application & Required Forms Checklist (please circle) Have you fully completed and signed your Membership Form?............................................................Yes/No Have you signed and attached your EA Waiver Form? ……..………………………..…………………….Yes/No Have you signed and attached your Safety Booklet & Risk Assessment Acknowledgement? ……….. Yes/No Have you attached a copy of your EFT payment receipt?..................................................................... Yes/No Please note that receipt by MBARC of payment and all required forms is mandatory before you will be able to take part in any MBARC activity. Signature of applicant: ____________________________ Date: _________________________ Fees for 2015/2016 riding year (1 Oct–30 Sep) Riding members: $90 (full year), $60 (half year joining after 1 April) Non-riding members: $25