Silver State Barrel & Pole Assoc. Membership Application

President: Suzanne Harmon     Treasurer: Stacey O’Farrell

Fill out one application per rider. Make a copy of this form for your records. Send original with your fees to: Suzanne Harmon 11256 Carlsbad Road Reno, NV, 89508

I have enclosed fees for the following: ___________ $50 Membership Fee ___________ $25 Additional Membership Fee for family member under 18 years of age. ___________ $35 2nd Membership for a person riding more than one horse. ___________ $35 3rd Membership for a person riding more than one horse. (2nd or 3rd Membership must be included with initial membership)

PRINT CLEARLY IN ORDER TO INSURE YOUR MEMBERSHIP IS CORRECT. PLEASE FILL OUT COMPLETELY. Email Address: ___________________________________________________________ Last Name ________________________________  First Name _____________________ Address _________________________________________________________________ City _____________________________________ State __________ Zip _____________ Home Phone ____________________________ Cell Phone ________________________

DISCLAIMER OF LIABILITY I agree to release and hold harmless the Silver State Barrel & Pole Association and all the people associated with the series, arena owners, arena operators and promoters, sponsors and any person connected with the Silver State Barrel & Pole Association from losses, damages, or injury to me, my equipment, and/or my animals resulting from attending and/or participating in any Silver State Barrel & Pole Association events. Signature ____________________________________________________________ Date ______________ DISCLAIMER OF LIABILITY If participant is under 18 years of age, a parent or legal guardian must sign this release. I agree to the above release and unconditionally give my permission for the applicant named herein to compete. Signature ____________________________________________________________ Date ______________