Shaping the hearts, minds & futures of San Antonio's youth—since 1984

San Antonio  Youth Centers, Inc. PO Box 7844  San Antonio, TX 78207   Ph: 210-223-3131   Fax: 210-223-9939   Info: melissa@sanantonioyouth.org

Copyright: 6/18/08

Chips & Salsa Credit Card Registration 

Please complete and submit this form to reserve your space at our event today!

 

Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail
URL

	BILLING
Credit Card #
Name as listed on the Card

 

Expiration Date
Type of Card:  Last three digits	Visa Mastercard American Express Discover

Please indicate if individual ticket purchase or sponsorship:

Prince & Princess:  $5,000

Royal Court:  $1,000

Individual Ticket:  $60 for 1, $100 for 2; at the door $75 for 1, $125 for 2

Participation Level:

	SHIPPING Address for Tickets
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

San Antonio Youth Centers, Inc.Revised: