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KHJA Membership Application

Payable via check or PayPal @

Single: $25.00 Family: $40.00 Barn/Club/Organization: $40.00

MEMBERSHIP FOR: ___________________________________________________ DATE: ___________________

Rider's Name(s)

Please Circle: Adult Child

Date of Birth (18 or under) KHJANumber Trainer’sName

STREET: _________________________________________________ CITY:____________________STATE:__________

ZIP: _______________ EMAIL: ________________________________ PHONE: _____________________

Newsletters, Rule Book, Entry Forms and Show Schedule all found online at

Rider/Horse Experience – Required Information 18" 2' 2'6" 3' 3'3" 3’6” 4’

Highest level RIDER has competed in last 36 months

Highest level HORSE has competed in last 36 months


I agree to participate, or my child/children,___________________________________________________, (listed above) have my permission to participate any KHJA show for the current

year. Every class entry at a KHJA competition shall constitute an agreement and affirmation that all participants (which included without limitation, the owner, lessee, trainer, manager,

agent, coach, driver, handler, rider and horse) for themselves, their principle, representatives, employees and agents; (1) Agree to hold the competition, its managers, officials, employ- ees and agents, the facility owners and operators and the KHJA and its Board of Directors harmless for any action taken; and (2) Agree that they participate voluntarily in the competi- tion fully aware that horse sports and the competition involve inherent dangerous risk of serious injury or death. In participation they expressly assume any and all risks of injury or loss

and they agree to indemnify the KHJA and its Board of Directors harmless from and against all claims including for any injury or loss suffered during or in connection with the competi- tion whether or not such injury, claim or loss resulted directly or indirectly from the negligent acts or omissions of said competition, its employees and agents or the facility owners and

operators. WARNING: Under Kansas law, there is no liability for an injury to or the death of a participant in domestic animal activities resulting from the inherent risks of domestic

animal activities, pursuant to section 1 through 4. You are assuming the risk of participating in this domestic animal activity. K.S.A. 60-4001 through 60-4004.Inherent risks of domestic

animal activities include, but shall not be limited to: (1) The propensity of a domestic animal to behave in ways, i.e. running, bucking, biting, kicking, shying, stumbling, rearing, falling or

stepping on, that may result in an injury, harm or death to persons on or around them; (2) The unpredictability of a domestic animal’s reaction to such things as sounds, sudden move- ment and unfamiliar objects, persons or other animals; (3) certain hazards such as surface and subsurface conditions; (4) collision with other domestic animals or objects, and (5) the

potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the domestic animal or not

acting within such participant's ability.

RIDER’S SIGNATURE (if over 18)___________________________________________________________________________________________________

PARENT/ LEGAL GUARDIAN SIGNATURE ___________________________________________________________PRINT: _______________________________________________

PROXY: As a voting member of the KHJA, if unable to attend the Annual Meeting, I name the President Elect as my proxy; Single and Family Memberships represent one vote.

Signature: ________________________________________________________________



c/o Debbie Beam

5721 NW Humphrey Rd

Topeka, KS 66618

Please Note: Horse, Rider, Owner/Lessee must all be KHJA members for

reduced entry fees and for all points earned to count toward Year-End


CHECK #_________

AMOUNT: ____________

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