Custom Payment – Junior – NVA Pass Academy

On-line Payment for the Pass Academy

Only use this form if you were requested by the office to make a custom payment.

"*" indicates required fields

Custom Payment Form

Player's Name*

First Last

Age*

Please enter a number from 8 to 18.

Parent Information

Parent's Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent's Email Address*

Enter Email Confirm Email

Parent Phone*

RENAISSANCE Payment Amount

Price: $1.00

Enter the dollar amount and press the Enter key

JDP Payment Amount

Price: $1.00

Enter the dollar amount and press the Enter key

SLHS Payment Amount

Price: $1.00

Enter the dollar amount and press the Enter key

Other Payment Amount

Price: $1.00

Enter the dollar amount and press the Enter key

Total Payment

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Additional Information (optional)

Medical Authorization & Release

Student's Name*

First Last

Student's Condition*

By checking this box it is understood that the student is in overall good physical health. If your child has a physical condition that may limit or restrict participation in certain activities, a physician’s note granting permission to participate in such activities must be presented prior to the first class session.

Date of Medical Authorization*

By dating above, in an emergency, when I/we cannot be contacted, I/we hereby authorize the staff of the Pass Academy to take my/our child to the emergency room of the nearest hospital. I/we authorize that hospital and its medical staff to provide treatment deemed necessary for the well-being of my/our child.

Date of Parent Release*

By dating above, I agree to hold the Pass Academy harmless for injury or loss that may occur as a result of my participation in Pass Academy activities.

Cancellation Policy*

By checking this box I accept the following policy. No refunds will be issued once the class has begun. A credit may be issued due to a medical condition, note from Doctor required.

Permission for Photo Use*

Yes

No

I give permission for photos of my child participating in Pass Academy programs to be taken and used for the Pass Academy Website and/or Facebook page. We understand that if students are identified, only their first names will be used.

A Submit button will appear below when the Total Fees from your selections above are greater than $0.

Total-Fees

Junior Custom Payment

On-line Payment for the Pass Academy

Custom Payment Form

Parent Information

Medical Authorization & Release