MEMBERSHIP INFORMATION
Name: ___________________________________________________________
Address: _________________________________________________________
Phone:
(Home) _______________________(Cell) ______________________
E-mail address: _______________________________________________
Family member name(s): ______________________________
Family member phone: (Home) _______________ (Cell) __________________
Family member e-mail: __________________________________________
NOMINATION INFORMATION
Class: Open
_____Youth (15 & under) _____Pee Wee (8 & under) _______
Pee Wee or Youth:
Date of birth: _______________
Verified by: _________________________________
Signature of parent or guardian: ________________________________
2012 Membership and Nomination Fees:
Single Membership - $20
______________
Family
Membership - $30 ______________
First Open or Youth Nomination/rider or horse (circle one) -
$15
Horse’s name*: ______________________________________
Second Open or Youth Nomination/rider or horse (circle one) -
$15
Horse’s name*: ______________________________________
Third Open or Youth Nomination/rider or horse (circle one) -
$15
Horse’s name*: ______________________________________
Pee Wee Nomination/rider or horse (circle one) - $10
Horse’s name*: ______________________________________
TOTAL: $____________
*Entering your horse’s name:
Please remember to use the name you entered above
for your Nominated Horse on all race entry forms to be sure you get points for that horse. For example, if you use your horse’s
registered name on this form, don’t use his or her barn name on the race entry forms.
SBRA Office Use Only:
Amount paid _____________Date paid _____________Received by ____________________________
