eSports Summer Camp Registration Fee

Name of Student*
Students Date of Birth*
MM slash DD slash YYYY
Session Attending*
Enrollment Type*
Phone Number*
Email Address*
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name