Rider Membership Form 2016/2017 Season
SECTION 1: RIDER REGISTRATION
Riders full name…………………………………………………………………………………………...... ………………
Date of birth………………………...... Age now………………………………...... ……..
Address……………………………………………………………………………………………………......
Hm Phone#………………………...... ….....Mobile#......
Email…………………………………………………………......
Name of Horse / Pony…………………………………………………………………………………......
Age of Horse/Pony …………………………………………………………………………………………………………………………….
How long have you been riding current horse/pony?......
Brief description of your experience to date……………………………………………………………………………………..
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Please list any other clubs you have belonged to:…………………………………………………......
What certificates do you hold………………………………………………………………………………………………………………
What certificates do you hope to sit this season……………………………………………………......
What are your goals for this season…………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
Do you propose entering or trialling for any of the following events. (Please circle)
Neville TrophyTeams DressageDistrict Teams Dressage Mounted Games
Training Evenings
Do you have any Allergies or take any medicine that we should know about? Y / N
If yes please state………………………………………………………………………………………......
Contact details in case of emergency - Name………………………………………………………......
Phone#...... Mobile#......
SECTION 2: FEES
Please tick membership type: You are required to pay a fee to NZPCA in addition to the club enrolment fee.
Joining fee NZPCA, North Harbour and Area $54
Enrolment per child $195
Enrolment per child for 2 children $150
Enrolment per child for 3 children $120
Adult member NZPCA $15
$100 Working Bee Fee (please see SECTION 5: for details)
Fees are due on registration.
Payment is preferred by internet banking to Dairy Flat Pony Club.
Bank account 12-3087-0055269-01 (with PC fee and your surname as the reference). Please email your membership forms to
If paying by cheque please make your cheque out to Dairy Flat Pony Club and post it along with your enrolment form to: The Treasurer, Dairy Flat Pony Club, PO Box 118, Waiwera 0950
SECTION 3: OFFERS OF ASSISTANCE
Are there any other ways in which you are able to help the Pony Club? (Please circle):
Sponsorship Fundraising MaintenanceProduct Donations
Assisting with Running Events Other; Please specify......
Donations of materials and / or Services for:
Jumps Paint Building Materials Furniture
Other; Please specify......
SECTION 4: PONY CLUB UNIFORM
Pony Club/ District or Area shirts must be worn at all rallies. Dairy Flat Branch colours are green & navy blue and size range is XS, S, M & L, the cost is of which is $50. Please place your order below.
Size: (please circle)
Child Sizes 468101214
Adult sizes SML XLXXLXXXL
SECTION 5: WORKING BEE
Pony Club is a family commitment and in today’s society, it’s fantastic to see parents and
children given the gift of time together.For the successful running of our branch rallies and our fund raising events we expect each family to contribute a minimum of 10 hours of work over the season. We will have a list of jobs to be done and families can sign up to them. We rely on the goodwill of all our families to help out and your contribution benefits all members. If you are genuinely unable to assist at rallies or at our events we ask you pay the $100 working bee fee instead.
SECTION 6: PRIVACY ACT
I the rider/parent responsible for the horse indemnify the land owner (Waste Management Ltd), NZPCA, Dairy Flat Pony Club from all claims losses and expenses including legal costs which may arise from or in connection with my membership in any activity I participate in whilst on the grounds of Dairy Flat Pony Club.
I give consent for my name, address, phone number and other information hereon, to be used in forming part of a membership list which may be published and distributed to other members and/or clubs. I give consent toinclude my photograph or other imagery on the Branch, Club, Area and/or NZPCA website, in newsletters, annual reports, or similar official publications.
Diary Flat Pony Club is a member of the ‘Fair Play Sports Charter of NZ’ and the ‘NZPCA’ and by signing this form I agree to abide by their rules and Pony Club rules. WE RUN UNDER THE NATIONAL GUIDELINES OF THE NEW ZEALAND PONY CLUBASSOCIATION THE MANIFESTO OF RULES AND REGULATIONS IS AVAILABLE ON THE NZPCAWEBSITE AND FORMS OUR CONSTITUTION.
SECTION 7: HEALTH AND SAFETY
1. All individuals who enter the pony club grounds must wear closed footwear – no exceptions
2. Kicking: Any ponies or horses that kick or are likely to endanger other horses/riders
must have a RED RIBBON tied to the tail.
3. Unruly Horses: All horses must be under control at all times. Owners of dangerous
or unruly horses will be told to remove them.
4.Supervision: It is the sole responsibility of the parent to ensure junior riders have
adequate supervision when riding on Pony Club Grounds prior to and after rallies.
There is to be absolutely no jumping without supervision. Juniors must have
ADULT supervision when jumping.
5. Supervision (Rallies): All riding at rallies must be carried out under the supervision
of an instructor or other authorised person. Parental assistance is always welcome.
No one may ride in a reckless or dangerous manner and all riders must regard the
safety of others at all times.
6. Hard Hats: Approved safety hard hats MUST BE WORN AT ALL TIMES when riding on
Pony Club grounds. Check the NZPCA website for safety approvednumbers.
7. Pony Club Uniform: This is: safety approved crash helmet, jodhpur boots or long
riding boots. Jodhpurs and the Navy Blue DFPC club shirt or sweatshirt.
8. Dogs are not permitted on the DFPC grounds at any time.
9. Please drive with caution in the parking area, and be aware of children and horses.
Applicants signature…………………......
Parents signature………………………………...... (required if applicant is under 18 yrs)
All new members or members whose details have changed are required to complete the NZPCA membership forms as well – check the NZPCA website.
Important Dates:
Season commences from 19 October 2014 – 14December 2016, then 25th January 2017 -29th March 2017.