JUVENTUS ACADEMY SAINT LOUIS: MYSA Card PAYMENT FORM 2021-2022

Welcome to the online MYSA Card PAYMENT FORM for the 2021/2022 seasonal year for JUVENTUS ACADEMY SAINT LOUIS.

CARD FEES:

Secondary Player Card: $10.00

ADMIN Card (coach or TM): $19.00

Note: Primary players are paid thorugh the GotSport player registration

If you have any questions, please contact:

Kylie Braeseke | Juventus Academy STL Administrative Group
Cell/Text: (954) 482-2497

E-Mail: admin@juventusacademystl.com

TEAM INFORMATION

ASSIGNMENT #1

Player/Coach/Admin Name *

JUVENTUS STL TEAM Name *

Role *

Coach

Team Manager

Secondary Player (list secondary team) Secondary Player (list secondary team)

Age Group *

Team Gender *

Male

Female

ASSIGNMENT # 2

Player/Coach/Admin Name

JUVENTUS STL TEAM Name

Role

Coach

Team Manager

Secondary Player (list secondary team) Secondary Player (list secondary team)

Age Group

Gender

Male

Female

ASSIGNMENT # 3

Player/Coach/Admin Name

JUVENTUS STL TEAM Name

Role

Coach

Team Manager

Secondary Player (list secondary team) Secondary Player (list secondary team)

Age Group

Gender

Male

Female

PAYMENT AUTHORIZATION

I would like my payment to be deducted using the following type of account: *

CHECKING

SAVINGS

CREDIT CARD (5% fee applies)

Account Holder/Card Holder FIRST NAME *

Account Holder / Card Holder LAST NAME *

Cell Phone (XXX-XXX-XXXX) *

Billing Address (Street, City, State, Zip) *

BILL PAYER E-mail Address *

TOTAL AUTHORIZED PAYMENT *

Secondary Player: $10.00/each

Coach or TM: $19.00/each

Coach or TM (multiple teams - $19/each) - plz list how many teams for payment Coach or TM (multiple teams - $19/each) - plz list how many teams for payment

TOTAL PAYMENT AUTHORIZED: *

NOTES

Comments/Notes:

CHECKING / SAVINGS INFORMATION

Name of Bank

Name on Account

9 digit Routing #

Bank Account #

Billing Zip Code

TOTAL PAYMENT

DEBIT / CREDIT CARD INFORMATION

Name on Card

Credit Card Type

Credit Card Number

Expiration Date

Security Code

Billing Zip Code *

TOTAL PAYMENT

<<< 5% card processing fee will be added

PAYMENT AUTHORIZATION

Please read and sign: *

By signing this form, I authorize Juventus Academy Saint Louis and their parent company Karidis Group International to process my payment via the payment method noted above, for the amount indicated, and acknowledge that I will be responsible for bank fees if the payment is returned and is unable to be processed.

Enter the word in the image *
captcha

Electronic Signature (please type first and last name) *

Date (mm-dd-yyyy) * +

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