Pioneers Registration Form

Survival 101 Pioneers Website: survival-basics.weebly.com

627 Columbia Forest Blvd Email: 101survivalbasics@gmail.com
Waterloo, ON N2V2K7 TEL: 519-884-8310

Please COMPLETE, SIGN, and DATE this form for all participants. One form MUST be completed for each participant
Incomplete forms will result in delays at registration and may require a collect call to parents or guardians.

PLEASE PRINT
Participant Information
First Name: ________________________ Last Name: _____________________
Birthday date (MM/DD/YYYY): ______/______/______ Age:_____ Gender:___________

Participant Contact Information

Street Address:_____________________________
City:______________________________________
Province:______________________________________
Zip/Postal Code:__________________________
Country:_______________________________________
House #Number: ___________________________
Email:_________________________________________

Parent/Guardian Information
First Name: _____________________ Last Name: _____________________
Street Address (If Different):_________________________________
City:___________________ Province:_______________ Postal Code:__________
Country:__________________ Phone Number: _______________________
Email:_________________________ Cell-Phone #: _________________________

Emergency Contact Information

Emergency Contact Full Name: __________________________________
Emergency Contact Phone Number: _____________________________

The Price
The price for Pioneers is $150, but if you do order the camp and pay before
March 22nd, then you can get the Early Bird Price, $100, a Bargain!

You can pay with either cash, a check paid to the order of Matthew Yang
Zhou, or through Email at mattthew.zhou@gmail.com.
You can give them in person to Matthew Zhou.

Have Fun and Be Safe!

OWNED AND OPERATED BY ©L.I.F.E