<p> Club Fees Please include a printed club member list from your Webpoint account and highlight the memberships you are paying for. NO PAYMENTS WILL BE ACCEPTED FOR NON-REGISTERED MEMBERS! CLUB: </p><p>I wish to pay by Credit Card for all the fees below. I have included/sent a check </p><p>Include list of UNPAID memberships from Webpoint & Complete Credit Card Authorization Form.</p><p>Cost Quantity Amount Due Adult Membership $60 $ (Coach) Other Adult Membership $25 $ (Chaperone) $60 $ Junior Membership</p><p>Upgrade to Junior Membership $55 $ U11 Youth Membership $25 $ (scrimmage only) Practice Player $25 $ (practice and scrimmage only) Site Director Membership $20 $ (valid 5 days from start date) Background Screening Fee $20 $ (required for adults every 2 seasons) Region Hosted $40 $ IMPACT/SafeSport Certification</p><p>List Coaches & Date/Location to Register for IMPACT</p><p>Authorization for Credit Card Use PRINT AND COMPLETE THIS AUTHORIZATION AND RETURN. All information will remain confidential Name on Card:</p><p>Billing Address: </p><p>Credit Card Type: Visa Mastercard </p><p>Credit Card Number: --- Expiration Date: /MM/YY Card Identification Number: (last 3 digits located on the back of the credit card) Check if you approve the Region to hold this form for future transactions. (Cardholder will need to call or email Region Office for future transaction amount approval) I authorize to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement. </p><p>Cardholder – Please Sign and Date Signature: ______Date: ______Print Name: ______</p><p>Return the completed and signed form to the following: ERVA 7 S. Howard St. Suite 418 Spokane, WA 99201 [email protected] Fax: 509-290-5318</p>