Street Pounders Membership Application

Street Pounders
Membership Application
“Enjoying the ride of impacting the lives of young people to make them powerful in the
community they live in”
109 South Columbia Street
Bogalusa La, 70427
Contact # 910-303-3762
Name (Print) _________________Larry D. Lucas Jr
__________________________________ Date _9-3-2014________
Age: _37___ DOB: Month________June___________ Day: ____06____ Year:
Address: _____70433 8th St._________________________________
__________________Covington, La. 70433_______________________
Phone Number: ___________985.249.9502__________________________
Alternate Number: ___________________________________
Email address: __drluc20004@gmail.com______________________________
Job/Occupation: __Telecommunications, Webmaster, Entrepreneur_________
How did you hear about Street Pounders: ___________Family__________
Check any that apply
Own my own horse
Own my own trailer
Transport my horse
Shoe horses
Start horses
Good with CPU
Been in horse club
Looking for a horse
Want to learn to ride
Need help with horse
No place to keep a horse
Just want to trail ride
Good with finance
Note keeping
Show horses
Race horses
Have transportation
Just want to support SP
For Club Use Only
Signature: ______________________________________ (Under 18 Guardian signature)