MEMBERSHIP APPLICATION 2011
NAME
ADDRESS
CITY STATE ZIP
PHONE#( ) ApHC# E-Mail: _____________________
DUES Year in L.C.A.C. runs from Jan. 1st - Dec. 31st of each year.
$15.00 ( Single or Individual Membership )
$20.00 ( Any two family members )
$25.00 ( 3 or more family members, Parents & minor children )
FOR FAMILY MEMBERSHIP, LIST EVERYONE IN FAMILY WITH ApHC #’S:
Name ApHC # Youth DOB
_____________________ ____________
_____________________ ____________
_____________________ ____________
_____________________ ____________
_____________________ ____________
LIST ALL HORSES BEING SHOW IN 2009 SEASON WITH REGISTRATION NUMBERS
Horse Reg. #’s
_____________________
_____________________
_____________________
_____________________
(If needed, use a separate sheet of paper)
Mail to: Donna Sorrell Please make checks payable to LCAC.
Lake Champlain Appaloosa Club
55 Elm Street
Champlain, N.Y. 12919