Parents Information $75.00
*Name of Parent (first & last)
*Address (street name, city, state & zip)

Student Information
*Childs Full Name
*Age
*Sex (boy or girl)

Credit Card Information
*Name of Card (Visa or MC)
*Card Number
*Expiration Date
*SN Number (on back)
* Date of EFT Draw (1st or 15th)