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PALOS VERDES PENINSULA 4-H CLUB
PVP 4-H CLUB
ABOUT US
CA 4-H ENROLLMENT
Credit Card Authorization
CONTACT US
MONTHLY NEWSLETTERS
BOARD MEMBERS
CLUB PHOTOS
Leaders Page
PVP 4-H CLUB
ABOUT US
CA 4-H ENROLLMENT
Credit Card Authorization
CONTACT US
MONTHLY NEWSLETTERS
BOARD MEMBERS
CLUB PHOTOS
Leaders Page
PVP 4-H Club Credit card authorization form for
club enrollment dues
Credit card authorization form
4-H Member Name #1
*
First
Last
[object Object]
Choose One
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Youth Member $160.00 (Credit Card)
Youth Member $160.00 (Check)
4-H Member Name #2
*
First
Last
[object Object]
Choose One
*
Youth Member $160.00 (Credit Card)
Youth Member $160.00 (Check)
4-H Member Name #3
*
First
Last
Choose One
*
Youth Member $160.00 (Credit Card)
Youth Member $160.00 (Check)
4-H Member Leader Name #4
*
First
Last
[object Object]
Choose One
*
Youth Member $160.00 (Credit Card)
Youth Member $160.00 (Check)
* Only Approved 4-H Adult Leaders who are current certified volunteer fill in their name on the next two.
* If you are a going to be a new volunteer leader; please let Mrs. Keese know and she will send your name to the county office to begin the process of signing up.
4-H Adult Volunteer Leader Name #1
*
First
Last
[object Object]
Choose One
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Adult Volunteer Leader $30.00
4-H Adult Volunteer Leader Name #2
*
First
Last
[object Object]
Choose One
*
Adult Volunteer Leader $30.00
*
Indicates required field
Parents/Adult Volunteer Leader Payment Email
*
Mobile Number
*
Home Phone Number
*
Form of Payment (Select One)
*
Credit Card
Check
If you are paying via check; please make payable to PVP 4-H CLUB and mail to PVP 4-H CLUB 26750 Eastvale Road, Palos Verdes Peninsula, CA 90274
Type of Credit Card (Select One)
*
Visa
Mastercard
Discover Card
American Express
Credit Card Number
*
Credit Card Expiration Date (MM/YR)
*
Security Code (3-digit code on back of card)
*
American Express Security Code (4-Digit code on front of card)
*
Cardholder's Address
*
Line 1
Line 2
City
State
Zip Code
Country
I Authorize
Dee Keese
to charge the agreed amount to my credit/debit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.
* Please note: your credit card will be charged within 72 hours after you submit the credit card authorization form.
* Also, if you have more than 1 member; each member will be charged separately.
Here is a breakdown of the club enrollment fees below:
Youth Member:
Total cost per youth member =
$160
(Credit Card) or
$160
(Check)
Adult Member:
Total cost per adult volunteer =
$30
Cardholder Digital Signature
*
Submit for Processing
Payment needs to be submitted by September 1, 2018