Avondale Horse & Pony Club Incorporated
Affiliated with The Pony Club Association of New South Wales Inc.
Club Grounds: Catherine Street St Ives NSW 2075
Mailing Address: PO Box 157, Avalon NSW 2107
Member Registration Form
Application for:
 New Membership
 Renewal of Membership
 Transfer from another Club
Please complete this form and send to Secretary: Natalie Rochester
Post to P.O Box 157, Avalon, NSW, 2107;
email to nrochester21@bigpond.com; or hand in at club grounds.
PCANSW AFFILIATED MEMBERSHIP
This membership entitles you to full access of all club and PCANSW facilities, events, instruction, rally days,
Closed, Open, Zone, Area and State pony club events, Regional Schools and Clinics.
Please complete the information required below:
i.
Riders under 17 years are Junior Members and it is mandatory that at least one parent/guardian become
affiliated with the PCANSW.
ii. Riders 17 – 25 years are Associate Members and do not require a parent to be PCANSW affiliated.
iii. Any Parent of a Junior and/or Associate member may become a Senior Member. Senior members 25 years
of age, and over, are not permitted to ride for the purpose of receiving instruction or competing at Pony Club
functions. They may be permitted to ride for the purpose of assisting, demonstrating or supervision with the
approval of the Club Senior Instructor. Instructors or those applying to become Instructors, may, with the
approval of the Club Senior Instructor, ride and receive instruction at instructional schools.
iv. One Member Registration Form can be used per family.
Family name:
Rider 1 First Name
Circle: Junior / Associate
Date of Birth:
Circle: Junior / Associate
Date of Birth:
Circle: Junior / Associate
Date of Birth:
Horse name/s and Micro-Chip ID
Rider 2 First Name
Horse name/s and Micro-Chip ID
Rider 3 First Name
Horse name/s and Micro-Chip ID
PARENT DETAILS:
One PCANSW Affiliated Parent membership is Mandatory for Junior Members; Optional for Associate Members.
Parent membership is a Senior Membership.
Parent 1 Full name:
Address:
Phone (mob pref):
Date of Birth:
Work:
Email:
 Senior
Parent 2 Full Name (optional):
Contact phone:
Date of Birth:
 For
Parent Membership
information only
Email:
ASSOCIATE MEMBERS EMERGENCY CONTACT ** required information
Contact full name:
Relationship:
Mobile number:
Alternative number:
Membership Registration Form
Page 1 of 3
Avondale Horse & Pony Club Incorporated
Affiliated with The Pony Club Association of New South Wales Inc.
Club Grounds: Catherine Street St Ives NSW 2075
Mailing Address: PO Box 157, Avalon NSW 2107
Member Registration Form
PCANSW AFFILIATED MEMBERS MEDICAL AND HEALTH INFORMATION
RIDER:
Please note any rider medical or health condition we should be aware of:
HORSE:
Please note any horse medical or health condition we should be aware of:
ASSISTANCE LEVY **
Avondale Horse and Pony Club is run entirely by volunteers. We ask all members – regular pony club and grounds use only
members – to attend two maintenance days throughout the year. These days are traditionally held on a Saturday, and run for a few
hours. If members attend the required two maintenance days, they will not pay the bond when renewing next year, or can apply to
have the bond refunded if they do not renew the following year.
Please complete either statement A or B below:
A: I/we understand that parent volunteers are responsible for the running of Avondale Pony Club and I/we
agree to assist in order that my/our child/ren can enjoy the benefits of membership. As such I/we nominate
to undertake the duties required in the role of
and/or attend maintenance days as required by the Club from time to time.
B: In lieu of nominating for a Committee and/or Volunteer Role as stated above, I/we agree to pay the
required Assistance Levy to Avondale Horse and Pony Club
FEES AND SIGNATURES
PCA Fees
Club Fees
Total
$55
$130
$185
2 Child
$55
+$110
$350
3rd Child
$55
+$90
$495
$35
Nil
$35
$100
$100
$10
SCHEDULE OF FEES
1. PCANSW Affiliated Members
Junior Members U17yrs: 1st Child
nd
Parent (required for Juniors): Senior Member
Parent Riding Member (per person)
Key bond
Assistance Levy**(if appropriate; see above):
Amount
Payable
$100
Total Due:
Membership Registration Form
Page 2 of 3
Avondale Horse & Pony Club Incorporated
Affiliated with The Pony Club Association of New South Wales Inc.
Club Grounds: Catherine Street St Ives NSW 2075
Mailing Address: PO Box 209 St Ives NSW 2075
Member Registration Form
IMPORTANT NOTES (Your application cannot be accepted unless each item is initialled)
Read and
Initial
1.
I confirm that any PCA affiliated riders above can walk, trot, canter and safely control their horse(s). The final
assessment of this minimum skill requirement remains at the sole discretion of the Club Senior Instructor.
2. I understand that if my child is under the age of 17 I must arrange for a parent or adult guardian to be in attendance at
all times at each Rally Day or other event (even if held at an alternative location).
3. I agree to provide the above riders with a suitable mount and all suitable gear for both horse and rider as necessary to
enable them to participate safely in the riding services, activities and facilities provided by the Club.
4. I understand that if my child or their mount suffers from any medical conditions I must make these known to the
Club Senior Instructor and Secretary prior to my first Rally Day.
5. I understand that any member (junior/child/family, associate or Non-PCA membership) using the grounds does so
AT THEIR OWN RISK.
6. I agree to indemnify the Club and it’s Office Bearers in respect of any legal liability to the maximum extent permitted
by law that the Club or Officer Bearers may have towards the riders which in any way arises from the rider’s use of
the mount and/or gear provided by me and whilst the rider is participating in the horse riding services, activities and
facilities provided by the Club.
7. Non-PCA members cannot ride on the grounds on Club Rally days without permission of the Senior Instructor.
8. By signing this form I understand and acknowledge that horse sports are dangerous activities and horses can act in
sudden, unpredictable and changeable ways. I understand and acknowledge that serious injury or death may result
from horse sport activities and hereby indemnify Avondale Horse & Pony Club Incorporated and it’s Officer
Bearers from all liability to the greatest extent allowable by law in the event that either myself, children under my
care or the care of their nominated guardian suffer injury or death.
9. I agree that in the case of emergency the Club is authorised to have Medical and/or Ambulance Services called for
the above applicants and that I will bear the full costs of any such services.
10. I understand that parent volunteers are responsible for the running of Avondale Pony Club and as such I have either
nominated for a Committee or Volunteer role OR agreed to pay the required Assistance Levy.
11. I understand that any person who is or has been a member of another Pony Club during the last 5 years wishing to
join Avondale must obtain a transfer from their previous club and that transfer must accompany this Membership
Application.
Rider’s Signature (if 18 years and over)
If Rider under 18 years, I
Date:
(full name) am over the age of eighteen years and
am the parent or legal guardian of the rider/s named above.
In case of emergency, do you agree to have Medical and/or Ambulance Services called?
Signature of Parent/Guardian: ______________________________
Membership Registration Form
YES/NO
Date: ______________
Page 3 of 3