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ONE TIME CREDIT CARD AUTHORIZATION

I hereby authorize Hillside, Inc. to charge my credit card as indicated below for services provided by Hillside, Inc.:

Please note: $200 event fee is per attendee. If registering more than one person, enter the correct amount to be charged to your card.

Billing Informaton

Method of Payment

Amex Visa MasterCard Discover
/
Accepted Credit Cards

If you prefer, you can download a paper version of this form pdf, and return it to us via fax or regular mail.

Hillside prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation and marital or family status.

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