School Aged Child Care Registration Form - Michiana Family Ymca Page 4
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4ELECTRONIC FUNDS TRANSFER AGREEMENT
Required for all weekly participants
Checking
Savings
Name on Account: ___________________________________________
Bank Name: _______________________________________________
____________________________
__________________________
Bank Account Number:
Routing #
Account #
OR
Credit Card
Debit Card
Name on Card: ____________________________________________________________________________
Card Type: __________________
Card #: ___________________________________________________
3-Digit Code ________________
Expiration date: ______________
CHECKING, SAVINGS, CREDIT or DEBIT CARD PAYMENT AGREEMENT
Int. ____
The Michiana Family YMCA Electronic Funds Transfer will begin on the SATURDAY 12:00AM before the week my child will be attending
programming and then every SATURDAY 12:00AM for the weeks registered for. Due to different bank protocols there may be a delay in the
payment posting to your account. (The Saturday morning draft allows for Friday bank deposits).
Int. ____
The Michiana Family YMCA Youth Development Electronic Funds Transfer is a continuous payment plan. It is to my complete
understanding that if I wish to terminate or change my child care in any way, I must give the Michiana Family YMCA Youth Development
Director a one (1) week written notice prior to my next debit or transaction. If proper notice is not received, I will be responsible for tuition
regardless of whether my child attends the program or not.
Int. ____
The Michiana Family YMCA may, at their discretion, adjust the weekly rate plan applicable to child care. I understand that I will receive at
least a two (2) week notice prior to any new change.
Int. ____
Should any child care debit not be honored by my bank or credit card for any reason, I understand that I am still responsible for that
payment plus any additional charges incurred for processing. This is in addition to any service fee my bank or credit card company
requires. There will also be a late fee of $5 for every week that a payment goes unpaid.
Int. ____
Any participant with a draft return will be contacted by a Youth Development Representative. The payment process and continuation of
child care services will be discussed at this time.
Int. ____
Two returned savings or checking account drafts will necessitate a change in payment options that include credit card draft, debit card
draft, or payment at the YMCA.
Int. ____
Any unpaid balance of more than 1 week of tuition will require removal of child from programming until balance is paid and current. Any
balance of more than 1 week that is not paid within 30 days of return date will be sent to collections.
I hereby authorize the Michiana Family YMCA to debit the above account on SATURDAY mornings for the following week that my child is enrolled in
B.A.S.E., S.O.Y.I., Winter Adventure Day Camp, and/or Spring Break Adventure Day Camp.
Account Holder’s Signature ___________________________________________________________________
Date ______ / ______ / _______
OFFICE USE ONLY
MICHIANA FAMILY YMCA
Draft Set-Up
1201 Northside Boulevard, South Bend
(P) 574 287 9622 (F) 574 282 3752
Staff Initials: _______
Date: ___________
(W)
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