Secure Payment Form

Make a recurring payment to the Boys & Girls Clubs of the Big Pines

Recurring Payment Details:

Child's Name:

Club Membership Fee Amount:

Recurring Payment Amount:

Choose your schedule:

Number of Payments, "*" means indefinite:

Start Date of Payments (DD/MM/YYYY format):

This is for (donation, name of extension, etc):

Comments:

Billing Information:

Card Number:

Card Type:

Card Expiration Date:

MMYY

Card ID (CVV2/CID) Number:
[What is the Card ID?]

Company Name:

First Name:

Last Name:

Address:

Address Line 2:

City:

State:

Zip:

Phone Number:

Email Address (to send a receipt):