JUVENTUS ACADEMY SAINT LOUIS: MYSA Card PAYMENT FORM 2020-2021

Welcome to the online MYSA Card PAYMENT FORM for the 2020/2021 seasonal year for JUVENTUS ACADEMY SAINT LOUIS.

CARD FEES:

Primary Player Card: $25.00

Secondary Player Card: $10.00

ADMIN Card (coach or TM): $11.00

If you have any questions, please contact:

Kathy Powers | Vice President & COO
Cell/Text: (314) 570-7857

E-Mail: admin@juventusacademystl.com

TEAM INFORMATION

TEAM #1

JUVENTUS STL TEAM Name *

Gender *

Male

Female

Age Group *

Juve STL TM Name *

Juve STL Coach Name *

TEAM # 2

JUVENTUS STL TEAM Name

Gender

Male

Female

Age Group

Juve STL TM Name

Juve STL Coach Name

TEAM # 3

JUVENTUS STL TEAM Name

Gender

Male

Female

Age Group

Juve STL TM Name

Juve STL Coach Name

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 *

Late Addition: Primary Player: $25.00/each

Late Addition: Secondary Player: $10.00/each

Late Addition: Coach or TM: $11.00/each

TEAM PAYMENT TEAM PAYMENT

TOTAL PAYMENT AUTHORIZED: *

NOTES

Comments/Notes:

CHECKING / SAVINGS INFORMATION

eCheck Processing confirmation *

I understand that there is NO processing fee that will be added to my total if I elect the eCheck payment option.

Name of Bank

Name on Account

9 digit Routing #

Bank Account #

Billing Zip Code

TOTAL PAYMENT

DEBIT / CREDIT CARD INFORMATION

Card Processing fee confirmation *

I understand and approve the 5% card processing fee that will be added to my total ONLY IF I elect the debit/credit card payment option. I understand the amount will run as one total payment with the fee included.

Credit Card Type

Name on Card

Credit Card Number

Expiration Date

Security Code

Billing Zip Code *

TOTAL PAYMENT

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) * +

clear