Infusion 2011 Nyack/ATS Student Registration

Description: Nyack/ATS student registration for the Infusion 2011 event at $20. (Registrant must be a current student of Nyack College or ATS OR the spouse of a current student.)

In the comment field below, please provide your full name (required) and your church or group affiliation (optional).
Amount: $20 USD

PAYER INFORMATION (REQUIRED AND CONFIDENTIAL)

Full Name:
Street Address:
City:
State:
Zip Code:
Country:
Phone:
Valid Email:
Your Relationship to Nyack/ATS:
Other?

COMMENTS/ADDITIONAL INFORMATION

REQUIRED: Please provide your full name (required) and your church or group affiliation (optional).

BILLING INFORMATION

Amount Due: $20 USD
 
Card Number:
CID Number:
(numbers only, format MMYYYY, i.e. '042019')
Card Exp. Date:
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