Membership Form

　We would rather you email Nate or Diana for a better, printable form. Thanks, Nate dottiedart@frontier.com

Ohio Horseman’s Council, Inc.

Membership Application for Year 2012

(Membership is from January 1 to December 31)Lorain County Chapter( ) New ( ) Renewal Please Print clearly or type
__________________________
Address: ____________________________________________ City: ______________ State: ___ Zip: ______
Primary County: __________________________ or ( ) At Large
The Corral and State Newsletter are included in your membership fee.
Email:_______________________________________________
□
I do NOT want to receive the Corral. □ I do NOT want to receive the State Newsletter.
Name: _______________________________________ Phone No.: ____________________________
Spouse: ____________________________________________ Cell Phone No.:

OHC Basic Membership (Without Equine Excess Liability Insurance)
Type please circle your choice	Membership Fee	Chapter Charge	Total
Individual (1) / Student /Senior (65 as of Jan 1)	15.00	10.00	25.00
Family (2)/Senior (both 65 as of Jan 1)	25.00	10.00	35.00

　
OHC Plus Membership (With Equine Excess Liability Insurance)
Type
please circle your choice Membership Fee
Chapter Charge
Insurance
Total
Individual (1)/Senior (65 as of Jan 1)
15.00
10.00
20.00
45.00
Individual with minor children (under 18 as of Jan 1)
25.00
10.00
20.00
55.00
Family (2) (with or without minor children)
25.00
10.00
40.00
75.00
If family membership, list names and ages of dependents (this is needed for insurance purposes).
1.____________________ ____ 2. ____________________ ____ 3. __________________ ____ 4. ____________________ ____ 5. _________________ ____
(Name) (Age) (Name) (Age) (Name) (Age) (Name) (Age) (Name) (Age)
　
Your application
cannot be accepted without your original signature(s). If Family membership, both spouses/partners must sign; if Individual membership, applicant must sign; if Student and under 18, parent or guardian must sign. Also date this document. By signing this document, I(we) agree to the terms and conditions of the By-Laws of the Ohio Horseman’s Council, Inc.
SIGNATURE: __________________________________________________________________ DATE: _____________________
SIGNATURE: __________________________________________________________________ DATE: _____________________
(For Chapter Use Only)
Make checks payable to: Lorain County OHC
Send to: Diana Shick, Treasurer & Membership Chair
51420 State Route 303
Oberlin, Ohio 44074
Phone: (440) 935-2650

OHC Plus Membership (With Equine Excess Liability Insurance)
Type please circle your choice	Membership Fee	Chapter Charge	Insurance	Total
Individual (1)/Senior (65 as of Jan 1)	15.00	10.00	20.00	45.00
Individual with minor children (under 18 as of Jan 1)	25.00	10.00	20.00	55.00
Family (2) (with or without minor children)	25.00	10.00	40.00	75.00