Section I: Student Member Information

Rider's Name:  __________________________________________
Street Address:  _____________________________________________
City/State/Zip:  _______________________________________________
                     (Above is a ___ permanent     or ___ temporary address)
Home Phone:  (________) _______________________
Cell Phone:  (_______) _________________________
Email:  __________________________________________
DOB:  ________________             Gender:   ____ Male          ___ Female

SECTION II.  SCHOOL INFORMATION
(Include School information, even if riding on an independent/barn team.)
School Name:  _____________________________________________________
School Street Address:  _______________________________________________
School City/State/Zip:  ________________________________________________
School in county of ____________________
Type of school:  __ Public           __ Private        (__ Home School)
I am in the __ 6   __ 7  __ 8  __ 9 __ 10  __ 11  __ 12 grade
Principal/Headmaster's Name: __________________________________________
Principal/Headmaster's Phone #: (_______) ___________________________

SECTION III.  BARN INFORMATION
Barn Name:  ________________________________________________________
Barn Street Address:  _________________________________________________
Barn City/State/Zip:  __________________________________________________
Coach's Name:  _________________________________________________
I am a:  ___ New Member           __ Renewing Member*   (*My RIFNA # is ______)
*If renewing member, indicate:  Region ____    State _____     Zone __________

RIFNA encourages each member to attempt all three disciplines.  Please indicate your order of  preference for participating in (or learning) each of the following disciplines (i.e., if your first choice is Hunter/Equitation, followed by Western and then Dressage,  write a “1” in the box next to Hunter/Equitation, a “2” next to Western, and a “3” next to Dressage.)
Dressage ______       Hunter/Equitation _______     Western ______

SECTION IV:  PARENT INFORMATION
Mother/Female Guardian Name: __________________________________________
Mother Street Address:  ________________________________________________
Mother City/State/Zip: _________________________________________________
Mother Email:  _______________________________________________
Mother Home Phone:  (________) ________________________
Mother Cell Phone:  (________) _________________________
Mother Office Phone:  (________) _________________________

Father/Male Guardian Name: __________________________________________
Father Street Address:  ________________________________________________
Father City/State/Zip: _________________________________________________
Father Email:  _______________________________________________
Father Home Phone:  (________) ________________________
Father Cell Phone:  (________) _________________________
Father Office Phone:  (________) _________________________

SECTION V:  MEDICAL/INSURANCE/EMEGENCY CONTACT
(Please attach additional sheets if necessary)
Known Allergies:  __________________________________________________
Current medications name/reason:  ______________________________________
Physician's Name: _______________________________________________
Physician's Phone #:  (_______) ______________________________

Insurance Company Name:  ___________________________________________
Policy or ID#: ________________________________________________
Group #: _______________________________________
Type of coverage:  __ HMO   ___ PPO   __ POS    __ Other

If parents cannot be reached, please contact:  ________________________________
Contact's Phone #: (_______) __________________________

SECTION VI:  DUES
$50.00 payable to RIFNA via __ Check / ___ Money Order / ___ Credit Card / __ Debit