Junior Program Custom Payment

On-line PAYMENT for the Pass Academy Junior Programs at Potomac Swim & Tennis Club

Only use this form if you were requested by the office to make a custom payment in order to secure the student’s spot in the requested/recommended session.

"*" indicates required fields

Junior Program Custom Payment Form

Student's Name*

First Last

Age*

Please enter a number from 5 to 18.

Parent Information

Parent's Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent's Email Address*

Enter Email Confirm Email

Parent Phone*

Payment Amount *

Price: $1.00

Enter the dollar amount and press the Enter key

Total Payment

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Additional Information (optional)

Medical Authorization & Release

Student Name*

First Last

Student Condition*

By checking this box it is understood that the student is in overall good physical health. If your child has a physical condition that may limit or restrict participation in certain activities, a physician’s note granting permission to participate in such activities must be presented prior to the first class session.

Date of Medical Authorization*

By dating above, in an emergency, when I/we cannot be contacted, I/we hereby authorize the staff of the Pass Academy to take my/our child to the emergency room of the nearest hospital. I/we authorize that hospital and its medical staff to provide treatment deemed necessary for the well-being of my/our child.

Date of Parent Release*

By dating above, I agree to hold the Pass Academy and Potomac Swim & Tennis Academy harmless for injury or loss that may occur as a result of my participation in Pass Academy activities.

Cancellation Policy

By checking this box I accept the following policy. Cancel prior to 1st week: 90% refund. Cancel after 1st week: 80% refund. Cancel after 2nd week: 70% refund. No refunds after 3rd week. Medical reasons will be accepted with a doctor’s note.

Permission for Photo Use*

Yes

No

I give permission for photos of my child participating in Pass Academy programs to be taken and used for the Pass Academy Website and/or Facebook page. We understand that if students are identified, only their first names will be used.