Do you have a youth interested in participating at The Pioneer Center? Please fill out the New Member form below. Once this form is filled out, you will receive a TEXT MESSAGE from “Remind” to be added to our Pioneer Youth text updates. Please opt-in to these texts so you can stay up to date with any events and announcements!

Student Name

First Name

Last Name

Nickname

Birthday

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone Number

(###)

###

####

Allergies

Other medical conditions/history

Guardian Name

First Name

Last Name

Guardian Phone Number

(###)

###

####

Guardian Email

Do we have permission to take and share photos/videos of your student?

Yes

Is your student allowed to walk/ride their bike to/from the center?

Yes

Consent Form

By signing this form electronically you are agreeing to the following: As the parent/legal guardian of the named child above, I assure that I will be available by phone at the number listed above. I hereby voluntarily release, forever discharge the community, the corporation, its officers, directors, employees, volunteers and agents from any and all claims, demands, or causes of action, which are connected with my child's participation in the programs or the use of the equipment and facilities. I agree to pay for any and all medical expenses incurred and give permission to the doctor or health care professional to provide medical care if necessary. The information I've given is complete and accurate. By signing this ELECTRONIC form, I confirm that I have fully informed myself of the contents of this Parental Consent and Release Form by reading it before I signed it. I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect.