HOLY FAMILY CATHOLIC HOME EDUCATORS
Autumn Dance Cruise Secure Payment Form
Attendee Information
* All attendees must be members of approved groups. Completion of this form indicates agreement with and adherence to standards of attire -
http://hfche.org/boat
. * Note - tab/click between sections, do not press enter until all info entered.
Attendee First Name
Attendee Last Name
Attendee Age
Attendee Grade
Select One
9
10
11
12
Emergency Contact Name
Emergency Contact Home Phone
Emergency Contact Mobile Phone
Emergency Contact’s Relationship to Attendee
Order Summary
Order Date
To which group do you belong? (Must Select One)
Select One
$30 HFCHE
$40 AMHEA
$40 Our Lady of Guadalupe
$40 St. Edmund Campion
Invoice Number
Customer IP
Description
Credit Card Information
Name as on Card
Card Number
Card Expiration Date
CVV2/CID
Email Address
Pay By Check
Pay By Credit Card
Name as on Check
Bank Routing Number
Bank Account Number
Social Security Number
Drivers License Number
Drivers License State
Submit
