Shurn Family Reunion 2017 - V1.0

Shurn Family Reunion 2017 South Bend Indiana

This Form Uses The Square Payment Gateway
Registering for Yourself?*
Registering as a family member*
Payment Method ?*
First Name*
Last Name*
E-mail*

Home Phone
Cell Number
Street Address*
Apartment
City*
State*
Zip
_______________________________________________

Adults Age 18 & Older $75.00 Per Adult
Age 18 and Up $75.00 Per Adult*
Select or Leave Blank if None
Total-Adult
Calculated Amount
Full Name of First Adult*
Full Name
Full Name of Second Adult*
Full Name
Full Name of Third Adult*
Full Name
Full Name of Fourth Adult*
Full Name
_______________________________________________

Age 10-17 $50.00 Per Young Adult
Age 10-17 $50.00 Per Young Adult
Select Number You are Paying for or Blank if None
Total-Young-Adult
Calculated Amount
First Young Adult 13-17*
Full Name
Second Young Adult 13-17*
Full Name
Third Young Adult 13-17*
Full Name
Fourth Young Adult 13-17*
Full Name
_______________________________________________

Age 6-9 $25.00 Per Child
Age 6-9 $25.00 Per Child
Select Number You are Paying for or Blank if None
Total-Child
Calculated Amount
First Child Age 6-9*
Full Name
Second Child Age 6-9*
Full Name
Third Child Age 6-9*
Full Name
Fourth Child Age 6-9*
Full Name
_______________________________________________

Age 0-5 No Charge Per Child
Age 0-5 $00.00 Per Child
Select Number You are Paying for or Blank if None
First Child Age 0-5*
Full Name
Second Child Age 0-5*
Full Name
Third Child Age 0-5*
Full Name
Fourth Child Age 0-5*
Full Name
_______________________________________________

Adult Tee Shirt Ordering Section

$12.50
Adult Small
Adult Medium
Adult Large
Adult XL
Total-Adult-Shirts (S-1XL)
Calculated Amount
_______________________________________________

Adult Extra Large Shirt Ordering Section

$15.00
Adult 2XL
Adult 3XL
Adult 4XL
Total-Adult-Shirts-(2XL-4XL)
Calculated Amount
_______________________________________________

Children Tee Shirt Ordering Section

$10.00
Y-XSmall
Y-Small
Y-Medium
Y-Large
Y-XLarge
Total-Child-Shirts
Calculated Amount
_______________________________________________

Other Cost Section
Scholarship Amount
OnLine-Pay

Your payment will include a 3.9% processing fee, plus fifteen cents. This is a bank fee and is not a fee from the family.

If you want to change your payment method, use the back button to page (1) and change your payment method.
Check-Pay

If you are paying by check, select the date we can expect your check and you will be emailed the details of where the check should be mailed.

If you want to change your payment method, use the back button to page (1) and change your payment method.
Pay By Mail Total
Calculated Amount All Items Total
Pay On-Line Total
Total Includes Processing Fees
Date We Can Expect Check*

MonthDayYear

Additional Comments:
Should be Empty: