Member Application

Membership Status *

New Membership

Select Static Logo

Or Sticker

RENEWAL Membership decal available

Check which one you wish to receive with your membership. Additional decals are available for $1.00 each

Membership Classification (Check One) *

Individual $10

Family $15

Student $8

Business or Professional $20

Club $20

*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.

How did you hear about the CHC? *

Complete All Fields *

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

Volunteer Network Information

2012
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.

_____________________________________________
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Member Application

CT Horse Council 2012 Membership Application