QC Arabian Horse Club

Membership Form

QCAHC

20__ Membership Application

Name _____________________ FarmName _____________________

Address_____________________________________________

City, State, ZipCode____________________________________

Phone Number where you can be reached___________or____________

E-mail address _____________________________________________

Family memberships include adults and children through age 18 residing in one household.

Names to be included in membership: Birthday (month & day)

___________________________________________________

E-mail ands home phone will be printed in the directory unless you check here ( ).

Cell phone number(s) are for office use only, unless you check here ( ).

Birthdays are recognized in the newsletter unless you check here ( ).

Check # _____

Amount $____

Date Received

___/ ___ / ____

Initials: ____

Referred by: ___

Membership are valid from date of acceptance until December 31^st of the same year. New memberships received on or after the last show date of the season, typically mid -September, count toward the next year.

Make check payable to: “QCAHC”
Single Membership: $15.00
Family: $20.00

Mail to: Dennis Fortune

23905 Stagecoach Road
Geneseo, Illinois 61254

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