Group Swimming Lesson Subscription

Please enter information on the form below to process subscription for Group Swimming Lesson.

Username*

Password*

Retype Password *

First Name *

Last Name *

Organization

Address *

Address2

City *

Zip *

Country *

State *

Phone

Fax

Email *

Comment

Number of Children

Basic Group plan for 1 child ($135.00)

2nd Additional child (+$135.00)

3rd Additional child (+$67.50)

Child 1

Child 2

Child 3

Coupon

Payment Terms

$135.00 for each 1 month

Regular subscription price

Regular subscription discount amount

Regular subscription tax

Payment Fee

Regular gross amount

Payment Method

Authorize.net

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*