New Member Credential one- time payment Prorated

Please fill out this one time credentialing payment form choosing individual or couple payment and click submit.

Name

*

Spouses name if applicable

Email

*

This address will receive a confirmation email

Spouses Email if applicable

Phone

*

Address

*

Home Church/Ministry Name

*

Ministry Email

Ministry website

Text consent for reminders and special events only

*

Please select one option.

Yes No

By selecting "Yes" above, I am consenting to receive SMS messages from Breeze regarding information and announcements for The River Revival Network. I understand that message and data rates may apply and message frequency varies. I can opt out by responding STOP at any time. For support I can text HELP to 87447. Please review the Breeze Privacy Policy and Terms of Service available at breezechms.com for more details.

Choose by Quarter & Individual or Couple Pricing

Ind. 1st Quarter ($500.00) Ind. 2nd Quarter ($405.00) Ind. 3rd Quarter ($270.00) Ind. 4th Quarter ($135.00) Couple 1st ($700.00) Couple 2nd ($585.00) Couple 3rd ($390.00) Couple 4th ($195.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Please fill out this one time credentialing payment form choosing individual or couple payment and click submit.

Please Fix the Following

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