Swim Team Payment Form

If you would like to make a payment amount that is not listed here please call the Y at 617-625-5050

You can choose multiple payment options at once if you would like.

Child's Name *

First

Last

Parent's Name *

First

Last

Email *

Phone *

Are you signing up for a swim clinic? *

• Yes
• No

How much would you like to pay today? *

• $75
• $100
• $200
• $475
• $550

You can pick multiple options.

Swim Clinics *

• Tuesday April 23rd - Starts 1 - $20.00
• Wednesday April 24th - Starts 2 - $20.00
• Monday April 29th -Turns 1 - $20.00
• Friday May 3rd - Turns 2 - $20.00
• Monday May 6th- Backstroke 1 - $20.00
• Friday May 10th - Backstroke 2 - $20.00
• Monday May 13th - Breastroke 1 - $20.00
• Friday May 17th - Breastroke 2 - $20.00
• Monday May 20th - Butterfly 1 - $20.00
• Friday May 24th - Butterfly 2 - $20.00

Child's Medical Information *

If none write N/A

Card Information *

Card Number

MM123456789101112Expiration

/

YY2425262728293031323334

Security Code

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Total

$0.00

Signature *

Clear Signature

Submit