CHECK TYPE OF MEMBERSHIP: $15.00 ANNUALLY
 (  ) INDIVIDUAL   (  ) FAMILY   

DATE: _________ PtHA Membership # (if applicable):______________________________

NAME(S): __________________________________________________________________

NAME(S): __________________________________________________________________

ADDRESS: ________________________________________________________________

__________________________________________________________________________
                  (CITY)                                         (STATE)                                                  (ZIP)

PHONE: Daytime:____________________ Evening: _______________________

CHILDREN UNDER 19

NAME                     DATE OF BIRTH                                     NAME                     DATE OF BIRTH

______________________________________                  _____________________________________

______________________________________                  _____________________________________

AREAS OF INTEREST (CIRCLE)
   DRESSAGE                                  CLINICS                                HORSESHOWS

    DRIVING                                      PARADES                               TRAIL RIDES 

     OTHER

COMMENTS / SUGGESTIONS:
______________________________________________________________
______________________________________________________________
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