APPLICATION FOR ENROLMENT FORM 2019

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Ambrose Pitts
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1 PO BOX 3440 MIDLAND 6056 WHITEMAN PARK EQUESTRIAN CENTRE GNANGARA RD WHITEMAN PARK APPLICATION FOR ENROLMENT FORM 2019 (All applications subject to approval by committee) (ONE FORM PER RIDER - EACH FORM MUST BE COMPLETED IN FULL) RENEWAL NEW MEMBER TRANSFERING (HAVE YOU APPLIED FOR TRANSER) YES NO RIDER DETAILS NAME OF RIDER AGE AS OF 1/1/2019 DATE OF BIRTH GENDER: M OR F ADDRESS ADDRESS: POST CODE MOBILE NUMBER HORSE / PONY DETAILS STABLE NAME OF HORSE 1: SHOW NAME HORSE AGE: : HORSE HEIGHT SEX: STABLE NAME OF HORSE 2: SHOW NAME HORSE AGE: : HORSE HEIGHT SEX: STABLE NAME OF HORSE 3: SHOW NAME HORSE AGE: : HORSE HEIGHT SEX: PONY CLUB EXPERIENCE: NUMBER OF YEARS NAME OF CLUB CERTIFICATES PASSED (PLEASE CIRCLE IF PASSED) D D* C C* K B A

2 EXTRA INFORMATION FOR NOMINATED GUARDIAN (ADULT SUPPORT FOR RIDER UNDER 18YRS) NOMINATED GUARDIAN: ADDRESS DATE OF BIRTH: (THIS IS REQUIRED FOR INSURANCE PURPOSES) PHONE NUMBER HOME: MOBILE : DO YOU HAVE A CURRENT WORKING WITH CHILDREN S CARD? YES/NO NUMBER: DO YOU HAVE A CURRENT FIRST AID CERTIFICATE? YES/NO EMERGENCY CONTACT NAME FOR PARENT OR GUARDIAN NAME MOBILE COMPULSORY CLUB CANTEEN DUTY ALL FAMILES WILL BE REQUIRED TO DO CANTEEN DUTY THROUGHOUT THE YEAR AT RALLIES ON A ROSTERED SYSTEM. NOMINATED PERSON: CONTACT PH NUMBER: ADDRESS:

3 2019 MEMBERSHIP FEES Fee Type Quantity Price Ordinary Riding Member (under 17 years) x $315 Associate Riding Member (17 years and over) x $315 3 Rally Rider (9-24years) x $165 3 Rally Rider (25years & over) x $165 Leadline Rider (must be 4yrs of age or over) x $165 2 Riding members (Same Family) x $480 3 Riding Members (Same Family) x $645 2 Leadline Members (Same Family) x $270 2 Riding Members (1 Leadline 1 Ordinary Riding Member) same family x $375 3 Riding Members (1 Leadline 2 Ordinary Riding Member) same family x $565 Rider Insurance (Compulsory) x $115 Affiliate Riding Member (25yrs & over ) x $315 Affiliate Riding Member (25yrs & over ) Insurance Compulsory x $157 Adult Supporter (Compulsory for parent/guardian for riders under 18 years) x $54 Committee Members (Compulsory adult support insurance) x $54 Busy Bee Levy- Per Family (Compulsory) Renewing families may roll over from prior year x $120 Stables (optional) for use at rallies only x $35 Stalls- available for ponies only (optional) Limited available for use at rallies only x $25 TOTAL AMOUNT PAYABLE ALL MEMBERSHIPS ARE NOW TO BEEN DONE ON LINE VIA THE PCWA WEBSITE MY PONY $250 DEPOSIT REQUIRED PER RIDER (IF PAYING DIRECT DEBIT) TO SURCURE MEMBERSHIP NON-REFUNDABLE!! CREDIT CARD PAYMENTS ARE REQUIRED TO BE PAID IN FULL!! NON REFUNDABLE ALL FEES PAYABLE BY 1 ST MARCH 2019 IN FULL NON REFUNDABLE PLEASE NOTE FEES ARE REQUIRED TO BE PAID IN FULL BEFORE PCWA MEMBERSHIP CARDS ARE RECEIVED PAYMENT ACCEPTED CASH, CHEQUE, DIRECT DEPOSIT ONLY BANKING DETAILS HORSEMENS PONY CLUB BSB ACC COMMONWEALTH BANK CREDIT CARD PAYMENTS ALSO ACCEPTED ONLY VIA MY PONY ONLINE REGISTER FEES DO APPLY

4 CONDITIONS OF ENROLMENT 1. If you are a riding member of the pony club, you must participate in all lessons or instruction set for the rally. 2. That the riding member and or their appointed guardian UNDERSTAND and AGREE that they are totally responsible for the care of their horse/pony, including the provision of adequate food and water for their horse/pony. 3. For members under 18 years of age, a parent MUST remain to supervise their child throughout the day at pony club events (including rallies). Should a parent not be able to remain on the grounds all day or on a particular occasion, another adult must be appointed to supervise the child. If there is no adult supervision the child WILL NOT BE ALLOWED TO RIDE. 4. A riding member or a family member must attend at least 3 designated club duties throughout the year (Busy Bee). Club duty DOES NOT include rostered duties assigned for setting up and dismantling of equipment, or any other rostered jobs at rallies. B. COMPULSORY CLUB DUTIES need to be performed by the committee allocated times. Members must complete the first duty by the end of April 2019 and the last duty by the end of November C. COMMITTEE NOMINATED DUTIES ARE Activities for Grounds, Set up for events (NOT RALLIES), Duties at events held at Horsemen s pony club(not RALLIES), Prolonged assistance in the Horsemen s canteen. 5. Should a rider miss 3 rallies without giving notice to the Chief Organizing Coach or Rally Co-coordinator without a reasonable excuse, their membership will be cancelled without refund to enable a new member to join. 6. Enrolment signifies acceptance of the rules and regulations of the pony club of Western Australia. In particular riding members MUST wear an Australian Standard approved helmet when mounted and correct pony club uniform MUST be worn to rallies.

5 CONDITIONS OF ENROLMENT (continued) 7. Members must represent the club to the best of their ability, endeavor to be a valuable team member and adhere to Horsemen s pony club code of conduct at all times. 8. By signing this form, you give us permission for photographs and names of riding and nonriding members to be published in the club newsletter and on the club web site. 9. I understand Photographs may be taken during Rallies and Events I Consent to these being used on Horsemens Website and Social Media Pages I do not consent to these being used on Horsemens Website or Social Media PLEASE NOTE: As of the 1 st of January 2013 it is required that all riders are required to wear a correct fitting riding safety vest for ALL cross country and show jumping activities. (COMPULSARY NO EXCEPTIONS!!)

6 RIDERS DECLARATION FORM: I Have read (or have had them read to me) the conditions of enrolment as contained within this document and I have also have read (or have had read to me) the Horsemen s Pony Club Information and Guidelines Handbook for 2019 and I agree to abide by the conditions. I wish to be an affiliated pony club member, on the understanding that I must not belong to more than one pony club, and a surcharge appropriate to the PCWA Affiliation may be levied. I agree to be bound by the Constitution of the club and rules and regulations made by the committee from time to time and PCWA. Signed: Dated: PARENTS DECLARATION: 1 st PARENT S DECLARATION: Signature: Name: 2 ND PARENT S DECLARATION: Signature: Name: (Both Parents/ Legal Guardians to sign if a member is under 18 Years of age) DATE:

9 PONY CLUB ASSOCIATION OF WESTERN AUSTRALIA INC (PCAWA) (OVER 18 YEARS OF AGE) PCAWA DISCLAIMER STATEMENT CLUB NAME: The Horsemen s Pony Club Inc CLUB ADDRESS: WHITEMAN PARK EQUESTRIAN CENTRE GNANGARA ROAD, WESTERN AUSTRALIA I acknowledge and agree as a condition of participating in any PC or PCAWA event that neither the Club/Coach, participants, PCAWA or any subdivision thereof, officials, volunteers, medical personnel, any persons, promoters, sponsors, advertisers, owners and lessees of premises used to conduct the EVENTS, shall be under any liability for my death or any bodily injury, loss or damage which may be sustained or incurred by me, as a result of participation in or being present at the event, except in regard to any rights I may have arising under the Trade Practices Act 1974 (Cth) (or similar State legislation). I acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury, disability and property damage, can, and do happen. BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS DISCLAIMER. I ACKNOWLEDGE THAT THIS DISCLAIMER IS VALID FOR ALL AUTHORISED CLUB, ZONE AND STATE PCAWA EVENTS THAT I ATTEND WITHIN THE TWELVE MONTH PERIOD INCLUSIVE OF AND FOLLOWING THE DATE I HAVE SIGNED THIS FORM. Print Name Here Sign Here Dated

10 PONY CLUB ASSOCIATION OF WESTERN AUSTRALIA INC (PCAWA) PCAWA DISCLAIMER STATEMENT PARENT/GUARDIAN CONSENT FOR UNDER 18 YEAR OLD PARTICIPANTS I,.. being the parent/guardian of the above named,.., confirm that I have read the whole of this document and have taken all necessary actions to ensure I am aware of the activity which the above named, will be asked to participate in and consent to him/her participating. In doing so, I acknowledge that equestrian activities are dangerous and that accidents causing death, bodily injury, disability and property damage can and do happen. I agree that neither the club/coach, participants, PCAWA or any subdivision thereof, officials, volunteers, medical personnel, any persons, promoters, sponsors, advertisers, owners and lessees of premises used to conduct the EVENT(S) shall be under any liability whatsoever for the death or any bodily injury, loss or damage which may be suffered or incurred by the above named or by me in or being present at any PC or PCAWA EVENTS except for any rights the above named or I may have arising under the Trade Practices Act 1974 (Cth) (or similar State legislation). BY SIGNING HEREUNDER I CONFIRM HAVING READ AND UNDERSTOOD THE CONTENTS OF THIS DISCLAIMER. I ACKNOWLEDGE THAT THIS DISCLAIMER IS VALID FOR ALL AUTHORISED CLUB, ZONE AND STATE PCAWA EVENTS THAT I AND MY DEPENDANT ABOVE NAMED ATTEND WITHIN THE TWELVE MONTH PERIOD INCLUSIVE OF AND FOLLOWING THE DATE I HAVE SIGNED THIS FORM. NAME (BLOCK LETTERS) SIGNED

2017 TWILIGHT ENROLMENT DAY and DATES

2017 TWILIGHT ENROLMENT DAY and DATES Please join us as we kick off the new Pony Club year with this FREE event. Children of all ages are more than welcome to attend so please come along and meet our members,