Application for Membership

* - required field
*   I am eligible to become a Pioneer Yes No
*   First Name:     *   Last Name:
*   E-mail Address:
     Partner's Name:
     Birth Date: / / (yyyy/mm/dd)

     I was signed up by:

Address Information:

Home Address:
    Apt. #      Street:
    City/Town:     Postal Code:
    Phone Number:

    Work Address:
    Department:
    Floor:    Street:
    City/Town:
    Phone Number:

Volunteer Participation Information:

    Send me a yearly Pioneer Membership book: Yes No
    I would like to volunteer once a year for a community service project: Yes No
    I would like to be called for your next project: Yes No
    I would like to chair a project: Yes No

    My project interests are:
Cultural/Arts
Handicapped
Environmental
Children
Health
Education
Fundraising
Crafts
Phone tree
Senior Programs
Sports/Fellowship
Transportation

    I prefer to volunteer:
With my family
Weekends
Weekdays
Weeknights

    I have special skills in the following areas:
Carpentry/Woodworking
Communication/Public Relations
Sewing/Knitting
Computers/Electronics
Literacy/Tutoring
Marketing
Other (please specify)

I understand that the Pioneer dues are $15.00 per year and that the dues will be deducted from my pay cheque on the first pay period in July.
Applications are submitted to the Pioneer Director.

Thank-you for your application!
A Pioneer Representative will contact you with additional information.