"*" indicates required fields NOTE: Online Payment Accepted through PayPal ONLY. "Guest" payment (no PayPal account required) is allowed. SEE instructions below.ALL Data entered on this form is secure and encrypted. ADA does not collect, store or process credit card payments directly. All Form communication with PayPal is encrypted.Membership Effective December 1, 2023 through November 30, 2024Membership Applications received after December 1st go into effect as of date of receipt and payment. FIRST: Select Membership Type* Individual Membership Family Membership SECOND: Let us know if you are a Renewal or a Northern Arizona Chapter Member Renewal NAC (you must choose this to be a Northern Arizona Chapter Member) USDF #('s) … (If known) DIVISIONSAA (Adult Amateur) | Open (Professional) | Jr/YR (Junior – Ages 14-18; Young Rider – Ages 16-21)INDIVIDUAL/PRIMARY MEMBER INFORMATION – SEE ADD'L FAMILY INFO BELOW (if checked above)DOB will be required for JR/YR membership verification to USDF.Name* First Last DOB (Non JR/YR)(See DOB Below if you are a JR/YR) MM slash DD slash YYYY Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Enter Email Confirm Email Opt-In to Receive Important ADA Information by email. The ADA delivers the Centerline Newsletter and all Show and Event information electronically via Constant Contact! To receive the Centerline via snail mail, see optional additional hard copy fee below. MobileHome PhoneWork PhoneFAMILY MEMBERSHIPUse this Section for multiple Family Memberships BUT ONLY the PRIMARY Family Member gets one ADA vote . Each ADA Family Member gets a USDF Group (GMO) Membership with the Additional Fee.Primary Family Member Name (if different than above) First Last Name – Supporting Member #1* First Last Name – Supporting Member #2 First Last Volunteerism (Required for ALL Year End Awards, Scholarships and Travel Grants)The ADA relies on volunteers to run enjoyable, organized events, AND volunteering your time or expertise is required for Year End Awards, Scholarships and Grants. The ADA has many volunteer opportunities … even beyond those listed here. Feel free to contact any ADA Board member to find out more. Already know how you'd like to serve? Please check appropriate area(s) and we will contact you to coordinate your service. Volunteer @ Horse Shows Volunteer @ Clinics (auditor check-in, sound system, setup/take down) Serve on ADA Board Serve on ADA Committee (Fundraising, Shows, Awards, etc) Provide Event Venue Hospitality (Host a clinician or judge or competitor) Submit Articles, Barn Tips or Nuggets to the Newsletter Other (we will contact you to find out your idea) No time to Volunteer? Consider a Volunteer Donation (Optional) Volunteer Donation ($50) Oops! Undo Selection *** Membership Payment Options *** REQUIRED ***You MUST select one of these Division choices to load appropriate Membership fees! Don’t see any fees? Be sure to select a “Membership Type” at the top of this form!2024 Individual Member Division* AA – $58 Open – $58 Jr/YR – $58 2024 Primary Family Member Division* AA – $58 Open – $58 Jr/YR – $58 2024 Supporting Family Member #1* AA – $33 Open – $33 Jr/YR – $33 2024 Supporting Family Member #2 AA – $33 Open – $33 Jr/YR – $33 Oops! Undo Selection OPTIONAL: Business Card Newsletter AdvertisingSelect12 months Business Card ($180)6 months Business Card ($90)Upload Your BC if We Don't Already Have It! (or email a copy to [email protected]) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 100 MB, Max. files: 2. Please upload a JPG, PNG or PDF of your business card here if ADA does not already have one on file.JUNIOR/YOUNG RIDER DOB Required!Date of Birth is required by USDF to confirm Junior/Young Rider Age Eligibility.Junior/Young Rider DOB* MM slash DD slash YYYY Junior/Young Rider DOB* MM slash DD slash YYYY DOB – Supporting Member #1* MM slash DD slash YYYY DOB – Supporting Member #2* MM slash DD slash YYYY OPTIONAL $25 STATE CHAMPIONSHIPS HORSE NOMINATION Qualifying Scores Count AFTER Horse is Nominated, so don’t miss this chance to nominate your horse today! SEE ADA/TDC websites for qualifying criteria.2024 AZ State Championships Yes! Nominate my Horse Oops! Undo Nomination Show is held in November each year. Please consult ADA/TDC websites for qualifying criteria and location of this year’s show.Horse Name:* Horse USDF #:* Owner Name (If different from above): Owner Email/Phone (if different from above): Owner USDF #: Owner USEF #: OPTIONAL Donations/FeesYour generous donations help fund ADA Scholarships and Travel Grants for educational opportunities!$9 ADA Education Program Donation $9 Education Donation Oops! Undo Selection $5 Region 5 JR/YR Donation $5 Region 5 JR/YR Donation Oops! Undo Selection $1 USDF Region 5 Donation $1 USDF Region 5 Donation Oops! Undo Selection OPTIONAL $33 Hard Copy CenterlinePrinted Hard Copy Centerline Delivery Fee $33 Hard Copy Oops! Undo Selection VERIFY TOTAL – YOUR APPLICATION IS NOT COMPLETE UNTIL PAYPAL PAYMENT IS CONFIRMEDNOTE for GUEST PAYMENT: Choose “Pay with a Debit or Credit Card” on the next screen instead of logging in to Your PayPal account (not ADA). A PayPal account IS NOT REQUIRED to complete payment.Yes, We do need you to check this box to prove you're human! Thanks!TOTAL 2024 MEMBERSHIP APPLICATION FEES PhoneThis field is for validation purposes and should be left unchanged. Δ
