TIC Teen Programs

"*" indicates required fields

Parent Name*

First Last

Address

Street Address City State ZIP Code

Parent Phone

Parent Email*

I am registering my teen(s) for:*

Date/Name of Dinner

Amount:*

Teen's Name

First Last

Teen 2's Name (if applicable)

First Last

Teen 3's Name (if applicable)

First Last

Payment Method*

E-check

Credit Card — payment includes an additional 3% of the total to help defray credit card processing fees.

3% credit card processing fee:*

Price: $0.00

Total

ACH / E-check

Account Number Account Type Routing Number Account Holder Name

Credit Card

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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