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CUSTOMER
BILLING INFORMATION |
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First Name: |
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Last Name: |
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Address 1: |
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Address 2: |
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City, State: |
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Zip code: |
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Phone:
(333-444-5555) |
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Emergency Phone: |
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Fax: |
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Email Address: |
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STUDENT
ATHLETE INFORMATION |
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Please Fill this Section
out with the Information
about the student who
will be attending the
clinic at Play Like a
Pro. For Dodge
Ball Sign-ups, please
give us the names of the
players on your team
under (Misc.
Information) |
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First Name: |
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Last Name: |
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Age: |
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Birthday: |
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Email: |
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Sport(s) Played: |
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Misc. Information: |
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WHICH
CLINIC ARE YOU
INTERESTED IN
PURCHASING?
This is the amount your
credit card will be
charged. (Including Tax) |
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AVAILABLE
LITTLE SLUGGERS PROGRAMS |
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AVAILABLE
SPORTS BASH CAMPS AND
CLINICS |
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AVAILABLE
SUMMER CAMPS & CLINICS |
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Enter Discount Code: |
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CUSTOMER PAYMENT
INFORMATION.
**Please Note, The
Credit Card you provide
must match the billing
address stated above.
For any questions,
please
contact us
anytime. |
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Credit Card Type: |
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Credit Card #: |
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(Enter
without spaces) |
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Name on the Card: |
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Expiration Date: |
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3/4 Digit Security Code: |
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How did you hear about
us? |
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