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.

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 Quantity*
Price: $1.00
Enter the dollar amount and press the Enter key
Total Payment
$0.00
Credit Card*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: 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*
MM slash DD slash YYYY

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*
MM slash DD slash YYYY

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.

Junior Program Custom Payment

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

Junior Program Custom Payment Form

Parent Information

Medical Authorization & Release