Become a Member

O.H.I.O. EXCA MEMBERSHIP FORM

* Indicates required field

MEMBERS NAME *

First

Last

DATE OF BIRTH *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Payment Type *

Mailed Check Venmo PayPal

Venmo:
Elisa-Holmes-5

PayPal:
elisa.holmes60@gmail.com

Checks:
O.H.I.O. EXCA
P.O. BOX 5
HIRAM, OH
44234

TYPE OF MEMBERSHIP *

INDIVIDUAL $35 FAMILY $35 + $15 PER. PERSON

# OF FAMILY MEMBERS *

LIST FAMILY MEMBERS NAME -D.O.B. *

By electronically signing this document I give my permission for and also agree that my photographs, may be used for publicity purposes to educate and promote the activities and missions of the O.H.I.O. EXCA organization. Therefore, for myself/ my family, I knowingly and voluntarily assume all risks involved in my participation, and do hereby release O.H.I.O. EXCA and its members, trustees, officers, independent contractors, and agents from any and all liability, damages, cost and expenses arising out of or relating to bodily or psychological injury, loss, or personal property that may occur as a result of participating in this program. Please See O.R.C. SEC.2305.321 for more information on equine events.

Electronic Signature and Date *

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