Page 81 - 2015 State Finals Program

Kansas High School Rodeo Association Membership Application 2014-2015

Name: ________________________________________________________New Member___ _ Renewal_____
(First, middle Initial, Last name, no nicknames)

Renewal: KHSRA Back #:___________________________________ (same # as last year.)

Address: ___________________________________________________________________________________
(post office, street address, or 911 address)

City,State,Zip ________________________/________________/______ Age: _________DOB_____________

Name of Parent(s) or Guardian(s):________________________________________________________________

Home Telephone: __________________________ Cell Phone: mom__________________________________

Cell Phone: dad_____________________________ Contestant’s cell phone:_____________________________

Parent’s – Email address: ____________________________________________________________________

Contestant’s email address: __________________________________________________________________

(Please print neatly and legibly and underscores and dashes need to be noted so that I understand which is which)

Facebook Account(s) for those who want to be on the KHSRA Facebook page:

___________________________________________________________________________________________
(Please include 1 current email address for the member, plus at least 1 for the parents!! We will be sending
correspondence via email so it is VERY important that we have email addresses of everyone who wishes to receive
the newsletters and other announcements. If you do not have internet access please note that.)

I hereby certify that I am enrolled in _________________High School, and will be in the _______grade and
I will graduate in 20____(year).

____________________________________________/___________________
Signature/date of member

____________________________________________/__________________
Signature/date of parent

____________________________________________/__________________
Signature/date of parent

SEND FEES AND ALL MEMBERSHIP INFORMATION TO:
KHSRA – State Secretary – Suzan Adams

7762 Old Stage Road Junction City, KS 66441
Phone 785-238-7192 Email: khsrarodeo@gmail.com

Checklist of Items to be Returned to the KHSRA State Secretary

 National Application Form (both parents must sign even if divorced)
 Minors Release Form & W9 (W9 only if new member)
 Kansas High School Rodeo Association Application (include email addresses for parent and contestant)
 Hospital Release Form (will be emailed at a later date – form not included in this packet)
 KHSRA Fund Raiser Responsibility Agreement Form (will be emailed at a later date- form not in this packet)
 Enclose a check for $150.00 made payable to KHSRA
 Enclose a copy of your birth certificate (new members only)

Enclose a copy of your most recent grade card – if you competed in the 2014 State Finals – I have your last

 grade card on file and you do not need to submit again. Everyone else must submit one.
(must be passing 70% of classes to be eligible to rodeo.) New 2014 fall members enclose your spring 2014 grade card -

2015 spring new members enclose your fall 2014 grade card