Individual Registration

First Name *

Last Name *

Address *

City *

Country *

Province *

Postal Code *

Phone # *

Email *

Select what your wish to contribute to the Simcoe Curling Club

Your Contribution *

$250

$500

$600

Please enter any additional amount you wish to contribute. Your Total will be caclulated in the Payment Amount box below.

Additional Contribution Acount

Amount

$

Payment Method *

E-Transfer (EMT) Pay by Cheque

Billing Zipcode*

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*

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