Check type of membership and circle dollar amount applicable
Member Information (Head of Household):
Last name: ______________________ First name: _____________________
Street: ________________________________________________________
City: ___________________________ State: ___________Zip: ___________
Home Phone: ____________________Cell Phone: _____________________
Email address: __________________________________________________
Member Information (Partner):
Last name: ______________________ First name: _____________________
Street: ________________________________________________________
City: ___________________________ State: ___________Zip: ___________
Home Phone: ____________________Cell Phone: _____________________
Email address: __________________________________________________
Children’s name(s) and age(s):
Last name: ______________________ First name: __________________ Age: _____
Last name: ______________________ First name: __________________ Age: _____
Last name: ______________________ First name: __________________ Age: _____
Last name: ______________________ First name: __________________ Age: _____
Signature: _______________________________________ Date: _____/_____/_____
Signature: _______________________________________ Date: _____/_____/_____
Please mail application and check made payable to S.R.H.A. to:
Melany Moore - 25000 Hutchinson Rd - Los Gatos, CA 95033
Or pay via Zelle and send forms: summitriders23@gmail.com
Liability Release must be signed each year and by each person included in membership.
Please make copies as needed.
Updated September 2022
Copyright © 2023 Summit Riders Horseman's Association - All Rights Reserved.
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