2009 Membership Form

CLICK HERE TO DOWNLOAD THE 2010 MEMBERSHIP FORM AS A WORD DOCUMENT

THE PENNSYLVANIA COUNCIL ON THERAPEUTIC HORSEMANSHIP INVITES YOU TO RENEW OR INITIATE A MEMBERSHIP IN 2010 – Membership Year 1/1/09-12/31/09

_____ Individual Lifetime Membership: $500

_____ Individual Annual Membership: $35

_____ 2009 Pennsylvania Qualified Instructor Fee: $10 (To be paid by PQInstructors)

_____ Student Annual Membership (includes high school, college & program participant): $20

Name:

Address:

City, State, Zip:

County:

Daytime Phone: E-Mail Address:

Program Affiliation:

Program membership includes one (1) individual membership – please fill in the section above with all of the information for the center designated individual membership (if PQInstructor, include $10 fee).

_____ Program/Operating Center Lifetime Membership: $500

_____ Program/Operating Center Yearly Membership: $50

Program/Center Name (as it should appear in publications):

Address:

City, State, Zip:

County:

Daytime Phone: E-Mail Address:

Contact Name:

The PACTH is a 501(c)(3) non-profit corporation. We are grateful for donations of any size. If you cannot make a donation, consider passing this along to others to support the work of the Council.

_____ Tax Deductible Donation: $_______________

_____ May we list your name in the donor issue of our newsletter?

Name:

Address:

City, State, Zip:

County:

Daytime Phone: E-Mail Address:

Program Affiliation:

Total Payment:

Method of Payment: ___ Cash ___ Check (payable to PACTH) ____ VISA ___ MasterCard ____Discover

Name on card:

Card Number: Expiration Date:

Signature:

Mail form and payment to: PACTH, Ann O’Shallie,

346 Briar Ln., Chambersburg, PA 17202

Pennsylvania Council on Therapeutic Horsemanship