Youth Payment Form 2

    Name of Student(required)

    Email Address(required)

    Home Phone Number

    Mobile Phone Number

    What are you paying for? Please select one
    Green Fleet/BeginnersOptimist White Fleet/IntermediateOptimist AdvanceLaser ClassPrivate LessonsChristmas CampOther

    PAYMENT

    Card type - please select
    VISAMastercard

    Name of Cardholder

    Card Number

    Expiry Date - mm/yy

    Card Security Code (3 digit number on the back)

    Amount of Payment (US$)

    An Electronic Receipt will be emailed to you when processed.