Become A Youth Club Member

Students Name: (required)

Email: (required)

Parents Name: (required)

Age:

Grade:

School:

Date of Birth

Address:

Home Phone:

Cell Phone:

Emergency Name:

Emergency Phone:

Allergies:

---YesNo

If you answered Yes, please describe the Allergy and any special instructions you may have:

Any serious illness or injuries?

---YesNo

If you answered Yes, please describe the illness or injury and any special instructions you have have:

Primary Physician's Name:

Physician Address:

Physician Phone:

Carrier:

Card #:

ID #:

Name of Cardholder:

Bay Area Equestrian Club is authorized to take photos of myself and or my student during meetings and events. (required)

I AgreeI Do Not Agree

Riding Level:

---BeginnerIntermediateAdvanced

Riding Style:

---DressageHunter/JumperWestern

Interested in Veterinary Medicine?

---YesNo

If you are interested in Veterinary Medicine, Please tell us about your past experiences in the Veterinary field:

T-Shirt Size:

---Youth SmallYouth MediumYouth LargeYouth XLSmallMediumLargeXL

Do you own a horse?

---YesNo

At which stable do you ride?

Interested in serving on the BAE Club Board of Directors?

---YesNo

How did you hear about BAE Club?

If you saw a flyer, where was it located?

I have read and agree to the terms listed in the Waiver of Liability.

E-Signature: