Rock n Roll Bingo Player’s Registration – The Center for Specialized Services

Rock n Roll Bingo Players Form

Table Organizer Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Rock n Roll Bingo Ticket

Price:

Choose how many people at your table below.

How Many People at your table?(Required)

There are 8 people to a table. Tables are $200; Individuals can pay $25 a person

Names of Teammates / People At Your Table

Please list the first and last name of those sitting at your table. (you do not need to include yourself)

Yes, I would like to cover the 3.5% credit card transaction fee

I Agree

3.5% Processing Fee

Price: $0.00

Total

Payment Information(Required)

Cardholder Name

Card Details