NHSRA JuniorHighDivision Membership Application...

NHSRA Junior High DivisionMembership Application 2016-2017

Name:

Mailing Address:

City,

Country:

(Please Print Clearly or Type and Fill In All Blanks)

Phone.t

________. . . . ._ Z ip+4!Postal

OFemale Cell Phone:C__ J_. . _Email Address:

Gender: OMale

State/Province Dues .

As D competing member. you are eligible to enter any ofthe events offered for your gender, For statisticalpurposes, please check any and all of the events you are planning to enter any time this rodeo season.

Girls EventsD Barrel RacingD Pole Bendingo GoatTyingD Breakaway Ropingo 'ream RopingD Ribbon Roping

State/Province Attending School In: School Type: 0Public 0Private OHomc

Date of Birth: Month: Day: Year: Current Grade in School: 06 07 08Number ofAQHA Registered Horses: -----State/Province Association in which you are applying for mcmbersmp: ._ __.____. . . .__. . .._..__. . . ._ _._._

If you live in a different state than the one you arc applying for, have you submitted a signed transfer form? OYes 0No

Which Region/District (if applicable): Number of Years in JH Division (include current year): 00 01 02 03Cheek One: 0Rookie (1 st year) Member 0Renewing Member

Dues and Fees Cnmpeting Member ,..---------------------,czr Important -- Please Initial

NHSRA Jr. High Division Dues, NHSRA Times, f;Veslern Horseman

and Insurance _ $80.0Q)U.S_) or $59.00 (Foreign)

40.00Region/District Dues,." ,.., ,.., , $~jp..

~t 1 $1"'''' DO~ ....•••....•.••••......•...•••........•...••..•......•..••...•..•.. , __f!:U_' __

EVEN'rS

Boys EventsOTic-Down RopingDChute Doggingb~ ~

DGoatTyingDBreakaway RopingDTeam RopingDRibbon RopingDBull RidingD Bareback Steer RidingD Saddle Bronc Steer Riding

I understand that I receive a one-year subscription

to Western Horseman magazine as a benefit of my

NHSRA .lHD membership. Two dollars of my member-

ship dues will be applied to this one-year subscription.

Initial Here:

If you are a 1l(~1'1-'member, how did you learn about the Junior High Division?

DWebsite D Print Advertisement

(Which Publication)D Friend or Relative

D ·Trade Show Booth

DMembership PosterD Other (Please List)D Television Advertising

D FFA/School Poster

DFacebook or Social Media

Read and Sign BelowWe certify that the information supplied in this application is true and correct to the best of our knowledge and belief, and that the student applying for membership meets the quali-fteat ions and criteria for membership in the District/Region High School Rodeo Association Junior High Division, the State/Province High School Rodeo Association Junior HighDivision and that National High School Rodeo Association Junior High Division, By applying for and receiving membership in the District/Region, State/Province and the NationalHigh Schoo] Rodeo Association Junior High Division. wehereby agree to follow all rules and guidelines set forth by the Region/District. State/Province and the National HighSchoo] Rodeo Association Junior High Divisions to abide by all decision and rulings of the governing committees and boards of these associations.

Member's Signature: ..__ .. . . . _

Mother's Signature: ._

Fath er' s S ignature: ___._ .. __.. _ .. ..__.__._._.__.._._.._.. __ ____ .__. . ..____..__.__..__._.. .__. . _._.__ _ __ _.____ .•.• ,,_,_.. . _._.__ .. _. . __. _._

BOTH PARENTS AND/OR GUARDIANS MUST SIGN A.PPUCATIONC(}MPLETE THE RELEASE FORM ON THE REVERSE SIDE OF THIS APPLICATION

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