Casual Member Agreement

Surname * First names *

Post code Email *

Phone: day Evening Mobile *

Surname * First names *

Phone: day Evening Mobile *

I acknowledge and agree that I do not have any medical conditions which may impact on my participation in the above Event/Activity, or if I do, I have disclosed them above.

I also agree to NZPCA (located at PO Box 7537, Taradale, Napier, 4141) holding such information included on this form and as I supply to it or authorise it to collect in respect of me or which otherwise comes into its possession, and authorise the release of this information to NZPCA Members or any other persons or organisations that the Board of NZPCA may think conducive to furthering the interests and objectives of NZPCA.

I understand that my personal information will be held securely by NZPCA, that I will have access to it and that it will be corrected upon request from me under the Privacy Act 1993.

I understand and acknowledge that I will be bound by the NZPCA Constitution, Regulations, and policies while participating in Limited Pony Club Events and/or Activities.

I will not hold the Branch, Club, Area or NZPCA or their respective officers responsible for any claims, losses, expenses and costs (including legal costs) which may arise from or in connection with my membership and/or participation in the above Event/Activity, except in the case of gross negligence or a wilful act or omission on the part of the Branch, Club, Area or NZPCA.

I indemnify the Branch, Club, Area or NZPCA from all claims, losses and expenses (including legal costs) suffered or incurred at any time as a result of, or resulting directly or indirectly from, my failure to observe the constitutions, regulations, policies, manuals, guidelines and reasonable directions of the Branch, Club, Area or NZPCA respectively.

I also understand that this Agreement only permits me to participate in the above Event/Activity.

I also acknowledge that I am the Person Responsible for any horse that I ride during Limited Pony Club Events and/or Activities.

Signature *

Clear signature Date

I am the parent/guardian/caregiver of the applicant who is under 18 years of age. I have read and understand this form and the Membership Declaration. I consent to the applicant's application for membership on the basis set out in this form and the Membership Declaration.

I also consent, or am authorised to consent, that the applicant does not have any medical conditions that may impact on their participation in the above Event/Activity, or if they do, I have disclosed them above.

I acknowledge that because the applicant is under 18 years of age, when I am present at a Limited Pony Club Event and/or Activity in which the applicant is participating, I am the Person Responsible for any horse that the applicant rides at a Limited Pony Club Event and/or Activity.

I also understand and acknowledge that as a Person Responsible for a Horse I will be bound by the NZPCA Constitution, Regulations, and policies while the applicant participates in Limited Pony Club Events and/or Activities.

Surname * First name *

Phone: home Work Mobile *

Signature *

Clear signature Date