Card replacement form

If you have received this link, your payment was unable to be processed. Please fill this out with the most up-to-date payment information you have. If you have any issues with the completion of this form or questions in regards to billing, please email info@canessouthwest.com. Thanks.

Location

Student-Athlete Information

Player Name

First Name

Last Name

Team/Age Group

Player DOB

YYYY

Primary Phone Number

(###)

###

####

Payment Information

Credit Card information is required for paying deposits, monthly dues, and uniform fees. Please discuss payment structure and format with Coach Senf. Thanks

Name on Card

First Name

Last Name

Credit Card #

Expiration Date

CVV Code

3-4 Digit Number on the back of your card

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PARENT/GUARDIAN AGREEMENT

I/WE HAVE READ THE BELOW AGREEMENT AND UNDERSTAND THAT I/WE GIVE UP CERTAIN RIGHTS BY VOLUNTARILY SIGNING THIS FORM. BY CHECKING THIS BOX, I AM ALSO CONFIRMING THE USE OF THE PROVIDING BILLING INFORMATION IN REGARDS TO THE AGREED UPON PAYMET STRUCTURE DISCUSSED.

I/WE UNDERSTAND THAT PHOTOS & VIDEOS TAKEN BY THE CANES ORGANIZATION ARE SUBJECT TO USE ON SOCIAL MEDIA AND FOR MARKETING PURPOSES

I/WE ARE COMMITTING TO THE CANES SOUTHWEST ORGANIZATION FOR THE SPRING 2019 SEASON, AND AGREE TO FOLLOW ALL GUIDELINES PRESENTED BY THE ORGANIZATION.