Name*
                            
                        
                    
                    
                                            

                            Email address*
                            
                        
                    
                    
                    
                                            

                            Project*
                            Lessenreeks Babyzwemmen (5 lessen)
Lessenreeks Watergewenning (5 lessen)
Lessenreeks Vakantielessen/Zwemschool (5 lessen)
Lessenreeks Privélessen (5 lessen)                        
                    
                    
                    

                        Amount () *Enter your own amount"90,00100,00130,00155,00"
                                                      
 



                    

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	                    I hereby authorize  to collect the amount shown above from my account periodically.