Member Application CT Horse Council Membership Application Please complete all fields below. Membership Status * New Membership w/Static Logo New Membership w/Sticker Check which one you wish to receive with your membership. Additional decals are available for $1.00 each Membership Classification (Check One) * Individual $20 Family $30 Student $15 Business or Professional $40 Club $40 *Note: Club Membership delegates are based on the number of club members. Please submit this form with main contact name. Attach listing of additional delegates with name, address, phone & E-mail address. RENEWAL Membership decal available Renewal How did you hear about the CHC? * Complete All Fields * CLUB or BUSINESS NAME (if applicable) _____________________________________________ NAME__________________________________________________________________________ STREET________________________________________________________________________ CITY / STATE/ ZIP_______________________________________________________________ TELEPHONE________________________________EMAIL________________________________ NUMBER OF HORSES OWNED * One Two Three Four or More AREAS OF INTEREST (Please check all that apply) * Trails Zoning Booth Legislation Website Emergency/Disaster Preparedness Volunteer Horse Patrol Education Horse 911 I would be willing to serve on a committee of my interest * Yes No More info, please I would be willing to have my name listed with CHC Connections as a person to contact in an emergency involving horses, or for emergency resources * Yes No More Info, please I would be willing to serve on a committee of my interest Please describe resources/services you would be able to provide in next section. I wish to join The Connecticut Horse Council, Inc. _______________________________________________________Date______________________ Signature Please Remember to send Checks to complete registration. Make checks payable to: The Connecticut Horse Council, Inc. Telephone: 860-482-9500 P.O. Box 57 www.cthorsecouncil.org Durham, CT 06422-0057 Please describe resources/services you would be able to provide Volunteer Network Information 2015 Connecticut Horse Council Connections is a volunteer network being developed to provide assistance and resources to our fellow horse owners in the state during times of natural or man-made disasters, or emergency incidents such as fires, loose horses, or trailer accidents. When there is an incident or emergency situation involving horses Connections will be a resource for local fire departments, first response dispatchers, and, as they continue to organize, with local CTSART Region Team Leaders. If you choose to participate in Connections, CHC will add your name to our list of people who can be contacted when help is needed. [ ] CHC has my permission to make my name available to my local Fire Department/local Emergency Dispatcher as an experienced horse-person to call in the event of an incident involving horse/s. My local FD is___________________________________________________________________ Local Police_____________________________________________________________________ [ ] CHC has my permission to contact me to provide emergency trailering for horse/s. Type/size of Vehicle_______________________________________________________________ [ ] CHC has my permission to contact me to provide temporary emergency shelter/housing/paddock space for horses which need to be relocated in emergency situations. Describe_______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ [ ] CHC has my permission to contact me to provide emergency supplies (feed, bedding, or other) for horses involved in emergency incidents. Describe_______________________________________________________________________ ______________________________________________________________________________ [ ] I am unable to participate at this time but would like to be included in future alerts or mailings. Although not yet mandated by Connecticut statute, the CT State Animal Response Team regions recognize the needs of large animals. CHC remains committed to assisting the five Region Team Leaders in their efforts to include horses in their disaster response plans. [ ] Please give me the contact name of my CTSART Region Team Leader so I can contact him/her. I attest that I am at least 18 years of age and that the information I provide The Connecticut Horse Council, Inc. is true and accurate. I understand that I may, in any particular situation, prudently decline to offer my good faith services. I further understand that The Connecticut Horse Council, Inc. acts only as a conduit for providing this information to individuals and/or organizations for the purpose of emergency response, and CHC is not liable for any injury or misadventure resulting in my volunteer efforts. _____________________________________________ Signature Secured Submitting
