Draft Authorization Form - Youth Programs printable pdf download

DRAFT AUTHORIZATION

YOUTH PROGRAMS

Participant Name _______________________________________________________________________________________________ Member ID# ____________________________

Parent/Guardian Name(s) __________________________________________________________________________________________________________________________________

Address __________________________________________________________________ City ________________________________ State __________ Zip _______________________

Email _________________________________________________ Phone (Home/Work/Cell) __________________________________________________________________________

BRIGHT BEGINNINGS PRESCHOOL REGISTRATION

PROGRAM START DATE _____________________________________

YMCA Member

Non-Member

Caterpillars (age 2)

 $810

 $865

Butterflies/Rockets (ages 3-4)

 $760

 $810

BEFORE- AND AFTER-SCHOOL PROGRAM REGISTRATION

PROGRAM START DATE _____________________________________

YMCA Member

Non-Member

Extended Care

Kindergarten Round-Up

 AM $75

 PM $100

 $550

 $600

SAFE ‘N SOUND

Name of School _________________________________________________________________________________________

5 Day Rate

3 Day Rate

YMCA Member

Non-Member

YMCA Member

Non-Member

BOTH

School Site

 $205

 $290  $370

 $235  $320  $410

 $135

 $180

 $225

 $165

 $210

 $255

YMCA Site

 $250

 $355  $440

 $280  $385  $470

 $160

 $225

 $280

 $190

 $255

 $310

Financial Aid/Discount

 YMCA  State/YWCA  3

Child  Employee  Kindergarten

Discount % or Amt. __________

PAYMENT INFORMATION

DRAFTS WILL BE MADE ON THE 1ST OF THE MONTH.

______________________________________________________________________

ACH DEBIT

Routing Number

Account Number

Voided Check

______________________________________________________________________

Required

Bank Name

Name on Account

______________________________________________________________________

CREDIT CARD

Account Number

Card Type

______________________________________________________________________

Cardholder Name

Expiration Date

Terms and Conditions

I agree to have the monthly fee(s) for child care automatically drafted from my bank account and/or charged to my credit card as outlined above.

It is my responsibility to inform the B.R. Ryall YMCA of any changes to my account. Should any draft be returned/declined by my bank for any

reason, I agree to pay the delinquent amount immediately.

Signature of account holder ____________________________________________________________________________________________ Date _____________________________________

Monthly Amount Due $ _________________________

Prorate $ _______________________________

FA Type _______________________

DIRECTOR USE ONLY

Facility _____________________________________________

Session __________________________________



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REV. 05.09.16