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NHSRA Junior High Division Membership 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 statistical purposes, please check any and all of the events you are planning to enter any time this rodeo season. Girls Events D Barrel Racing D Pole Bending o GoatTying D Breakaway Roping o 'ream Roping D Ribbon Roping State/Province Attending School In: School Type: 0Public 0 Private OHomc Date of Birth: Month: Day: Year: Current Grade in School: 06 07 08 Number 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 0 No Which Region/District (if applicable): Number of Years in JH Division (include current year): 00 01 02 03 Cheek One: 0Rookie (1st 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. 00 Region/District Dues,." ,.., ,.., , $~jp.. ~t 1 $1"'''' DO ~ ....•••....•.••••......•...•••........•...••..•......•..••...•..•.. , __f!:U_' __ EVEN'rS Boys Events OTic-Down Roping DChute Dogging b~ ~ DGoatTying DBreakaway Roping DTeam Roping DRibbon Roping DBull Riding D Bareback Steer Riding D 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 Poster D Other (Please List) D Television Advertising D FFA/School Poster D Facebook or Social Media Read and Sign Below We 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 High Division and that National High School Rodeo Association Junior High Division, By applying for and receiving membership in the District/Region, State/Province and the National High 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 High Schoo] 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 i gnature: ___._.. __ .. _ .. .. __ .__ ._._. __ .._._ .._ .. __ ____ .__ . . .. ____ ..__ .__ ..__ ._ .. .__ . . _._. __ ___ _.____ .•.•,,_,_.. . _._. __ .. _. . __ . _._ BOTH PARENTS AND/OR GUARDIANS MUST SIGN A.PPUCATION C(}MPLETE THE RELEASE FORM ON THE REVERSE SIDE OF THIS APPLICATION I
