Custom Payment – Junior – NVA Pass Academy

Junior Custom Payment

On-line Payment for the Pass Academy

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

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 Quantity
Price: $1.00
Enter the dollar amount and press the Enter key
JDP Payment Amount Quantity
Price: $1.00
Enter the dollar amount and press the Enter key
SLHS Payment Amount Quantity
Price: $1.00
Enter the dollar amount and press the Enter key
Other Payment Amount Quantity
Price: $1.00
Enter the dollar amount and press the Enter key
Total Payment
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: 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*
MM slash DD slash YYYY

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*
MM slash DD slash YYYY

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.

Junior Custom Payment

On-line Payment for the Pass Academy

Custom Payment Form

Parent Information

Medical Authorization & Release