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Home>Clinic Credit Card Payment form

MHSFCA Clinic Registration
Pay by Credit Card

Name (same name used to register):

School:

Individual Registration:

$90.00 per coach

Staff Registration:

Class A: $810.00 (9 or more coaches)
Class B: $630.00 (7 or more coaches)
Class C: $450.00 (5 or more coaches)
Class D: $270.00 (3 or more coaches)

Enter your credit card information below:

Credit Card Number:

Exp Date

Zip Code:

3-Digit Security Code (on back of card):

Amount: $

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