* Student First Name:

* Student Last Name:

*Age of Student:

*Grade Completed by June 2017:

*School Attended:

*T-Shirt Size:

Medical Conditions:

Convenience Fee (2.9%):
      (Convenience fee applies to the following payment methods: Credit Card)



Please enter the credit card information requested below:

*Card Holder's First Name:
*Card Holder's Last Name:
*Postal Code:
*Credit Card Number:
*Credit Card Type:
*CVV2 / CVC2 / CID (located on the back of the card):
*Expiration Date (MMYY):
*Enter Email Address for Receipt:
*Enter Daytime Telephone: