Fields in red are required fields and MUST be completed.

first name:
last name:
address:
city:
province:
postal code:
home phone:
work phone:
cell phone:
birthday:
email:
payment type:	==SELECT== PayPal - $10 Cheque - $10 *selecting PayPal will take you to the PayPal payment screen.
Please enter the text you see in the graphic below into the box to verify that this is a genuine application. If you cannot read the letters, please click on the graphic to generate a new image.
CONFIDENTIALITY AGREEMENT I authorize the Victoria Pride Society to collect and maintain the above personal information. This information will be used to advise me of current and future VPS events. My name and address will be retained on file. My information will be used for these purposes only and shall be held in strict confidence.