On-Line Registration Form

On-Line Registration

Contact Information

Name

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
E-mail

Choose one of the following options:

First Participant's Information

Name
Address	Same As Above
Date of Birth
Sex	Male Female

Please provide the following program information:

*Name of Program #1*
Program Number
Program Cost
Shirt Size

Please provide the following program information:

Name of Program #2
Program Number
Program Cost
Shirt Size

Second Participant's Information

Name
Address	Same as Above
Date of Birth
Sex	Male Female

Please provide the following product information:

Name of Program #1
Program Number
Program Cost
Shirt Size

Please provide the following product information:

Name of Program #2
Program Number
Program Cost
Shirt Size

Payment Information

Choose one of the following payment options:

	Enter your credit card number in the space provided below.
	Enter your expiration date in the space provided below.
	If you are using VISA or MasterCard please enter your "V" code in the space provided below. (the last three numbers on the back of your card)
	Enter the name that appears on the credit card in the space provided below.

Send mail to sandwichparkdistrict@comcast.net with questions or comments about this web site.
Copyright © 2008 Sandwich Park District
Last modified: 08/23/10