Pay Weekly Fees Your Name* First Last Phone*Email* Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Are you paying weekly fees for a Traditional or School-based Club?*TraditionalSchool-BasedSelect Traditional Club LocationTraditional Club Location*Select ClubEast DallasCedar SpringsGrand PrairieMesquiteNavarro CountyOak CliffRichardsonRoselandWest Dallas (fmrly Trinity River Mission)Select School-based Club LocationSchool-based Location*Select ClubKIPP DestinyKIPP Pleasant GroveUplift Wisdom Boys & Girls ClubWilliam Lipscomb ElementaryClub Member InformationWhat week are you paying for?*Jan. 19- 22Jan. 25- 29Feb. 1- 5Feb. 8- 12Feb. 16- 19Feb. 22- 26March 1- 5Number of kids ages 6-12*Number of kids ages 13-18*Child(ren)'s names and ages for who you are paying for*Price* Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name
