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PALOS VERDES PENINSULA 4-H CLUB
PVP 4-H CLUB
Leaders Page
PVP 4-H CLUB
Leaders Page
PVP 4-H Club Credit card authorization form for
club enrollment dues
Credit card authorization form
4-H Member Name #1
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First
Last
[object Object]
Choose One
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Youth Member $150.00
4-H Member Name #2
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First
Last
[object Object]
Choose One
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Youth Member $150.00
4-H Member Name #3
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First
Last
Choose One
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Youth Member $150.00
4-H Member Leader Name #4
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First
Last
[object Object]
Choose One
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Youth Member $150.00
* 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
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First
Last
[object Object]
Choose One
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Adult Volunteer Leader $20.00
4-H Adult Volunteer Leader Name #2
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First
Last
[object Object]
Choose One
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Adult Volunteer Leader $20.00
*
Indicates required field
Parents/Adult Volunteer Leader Payment Email
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Mobile Number
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Home Phone Number
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Form of Payment (Select One)
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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)
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Visa
Mastercard
Discover Card
American Express
Credit Card Number
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Credit Card Expiration Date (MM/YR)
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Security Code (3-digit code on back of card)
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American Express Security Code (4-Digit code on front of card)
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Cardholder's Address
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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 24 to 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 =
$150
($41.35 club dues, Square credit card fee $4.65, $54.00 4-H Insurance cost plus a $50.00 donation to the club)
Adult Member:
Total cost per adult volunteer =
$20
($1.15 club dues, Square credit card fee $0.85, $18.00 4-H Insurance cost)
Cardholder Digital Signature
*
Submit for Processing
Payment needs to be submitted by September 1, 2018