__ Single $10.00        __ Family $15.00                                                 _{___}Sponsor $60.00

(make check payable to CPWH and mail to 1218 Sunrise Beach RD Crownsville MD 21032)
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NAME(S): ____________________________________________________________________________      DATE: _____________

STREET ADDRESS: _________________________________________________________________________________________

CITY: _________________________________________________________  STATE: ______      ZIP: _______________________

DAY PHONE: (___) ________________                   EVE PHONE: (___) ______________                            FAX: (___)___________

EMAIL ADDRESS: __________________________________________________________________________________________

OCCUPATION: _____________________     NON-HORSE INTERESTS: __________________________________________________

How/Where did you hear about us? __ Friend    __ Internet   __ Flyer/Newsletter   __ Attended Event     __ Other:_ ______________ 

     ___I would like to recieve my newsletter via eMail                    ____   I do not wish this info to be shared with other club members

HORSE  #1:  NAME ______________________      COLOR _________________________     BREED ________________________

HORSE  #2:  NAME ______________________      COLOR _________________________     BREED ________________________

HORSE  #3:  NAME ______________________      COLOR _________________________     BREED ________________________

PLEASE CHECK YOUR INTERESTS:  __ Trail      __ Show     __ Parade      __ Demonstration     __ Planning      __ Membership

__ Newsletter     __ Publicity      __ Driving     __ Trailer Pooling - Have Trailer? __ YES     __ NO   Other: _____________________

Suggested topics, guest speakers or clinics______________________________________________________________________

Ideas for trail rides or trips____________________________________________________________________________________

May we send information to a friend? Include their address here ____________________________________________________

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