Victoria Program

Victoria, B.C.
Location
Program Start Date
Name*
First Last
Email*
Home Phone*
Cell Phone*
Birth Month*
This information will be used solely for the celebration of your birthday.
Birth Date*
Gender
Preferred Pronouns
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Referred By:
Referrer's Email
Referrer's Phone
Special Instructions / Comments:
Deposit & Confirmation:*
- Agree
I hereby agree to payment of this deposit of $1300 CDN (thirteen hundred Canadian dollars) to confirm my registration for the above noted program and understand that in this payment there is a non-refundable application fee of $250 CDN. I further agree that this online confirmation will be considered binding for all legal purposes.
Amount: ($CDN)*
Price: $ 1,300.00 CAD