FULL NAME: ___________________________________________________________

ADDRESS: _____________________________________________________________

CITY: _________________________________STATE & ZIP: ____________________

HOME NUMBER: _____________________WORK NUMBER: ___________________

CELL NUMBER: ______________________E-MAIL: ___________________________

DATE OF BIRTH: ________________________________________________________

PLACE OF EMPLOYMENT: _______________________________________________

EMERGENCY CONTACT: _________________________RELATIONSHIP:_____________

Do you have your own horse,tack and transportation? __________________________

Is your Application for RIDING or NON RIDING? ___________________________

If ‘RIDING’, please include current copy of coggins with application!

Tell us why you are interested in riding with the NCMP_________________________________________________________________

________________________________________________________________________

I understand by signing this application that I will ride at my own risk and with the understanding that neither this Organization or any member thereof, or any premise owner where the Organization rides shall be held responsible for any injury to person, mount, or equipment incurred while participating in any activity of this Organization.

____________________________ _____________________________

Print Name                                Signature

DATE Application received: ______________Received by: _______________________

Date: Approved - Disapproved________________________