Northern Counties Cutting Horse Association
Membership Application

Name: ___________________________________________

Spouse: __________________________________________

Children & age: ____________________________________

Address: _________________________________________

City: _____________________________________________

State: ___________________ Zip: _______________

Phone: (          ) _______ - _____________________

Email address: _______________________________

New    Renewal    Address Change

Family Membership Fee: $40.00. Membership includes spouse and children under the age of 18.

Print out and mail this form with your check to :
NCCHA, 6509 Fry Road, Dixon, CA 95620

NOTE: All Owners and Riders Must Be Members.
2001 CLUB YEAR January 2001 through December 2001

I hereby agree to release and hold harmless NCCHA, it's officers, members, guest or persons any way connected with NCCHA events from any loss, damage or injury resulting from my participation in said events.

Signed_______________________________________

Date _________________