St. Joseph's Center Secure Online Registration Form
  


Secure Online Registration Form

Please note that fields with an asterisk (*) are required.

RACE SPONSOR
 I would like to Sponsor the Night at the Races with a contribution of $100.
 Not at the moment



(Name as it should appear in the program)

TICKETS
Individual tickets at $10 per person. .00

RACE HORSES
horse(s) at $10 per horse. .00

HORSE NAME OWNERS NAME
Horse #1 
Horse #2 
Horse #3 
Horse #4 
Horse #5 
Horse #6 
Horse #7 
Horse #8 
Horse #9 
Horse #10 

Total amount $  .00

*First Name:  *Last Name: 
*Address 1:  Address 2: 
*City:  *State: 
*ZIP Code:  *Email: 
*Daytime Phone #:  Evening Phone #: 

*Credit Card #: 
*Exp. Date:  /


After ensuring that all of the information above is correct,
please click the Submit Form Now button ONLY ONCE.
Multiple clicks of the Submit button will result in duplicate charges to your account.
An email confirmation will be sent to the email address you provided.


 

  
Saint Joseph's Center
2010 Adams Avenue • Scranton, Pennsylvania 18509 • Phone: 570-963-1290 • Fax: 570-342-6080
Send us an e-mailwww.stjosephscenter.org


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