Club 21 Learning and Resource Center : What We Do : Club Connections : Club Connections Registration

Answering the questions below, will help our Club Connections Team create lessons that can meet a diverse group of needs.

Club Connections Payment Options

Payment in Full $500
$100 Deposit (must click box below for recurring payments)
Requesting Regional Center/Self Determination funding or applying for a scholarship

If you are requesting funding from your Regional Center, please check this box:

By checking this box, I understand that if my Regional Center does not approve my registration I will be responsible for paying Club 21 in full for the registration fee.

Payment Option

I will be paying for the program
I will be requesting Regional Center/Self Determination funding or applying for a scholarship (which is a separate form on the About Club Connections page).

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Visa MasterCard American Express Discover

Expiration Date (Required)

Security Code (Required)

Visa®, MasterCard® & Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Billing Zip Code (Required)

Make this a monthly payment?

Make this a monthly payment?

Club Connections