Child Care Payment Authorization Form printable pdf download

Child Care Payment Authorization Form

The Farifield YMCA strives to meet the needs of families! Due to the checking account (EFT) or credit

card draft plan, fees are automatically paid on time which means no late fees. Strict confidentiality of

this information will be maintained.

All fees will be drafted on the 20

of the preceding month services are rendered. (September’s payment

will be drafted on August 20

Monthly fees WILL NOT be prorated without Child Care Director approval.

This form MUST be turned in upon registration for childcare.

I, _____________________________________, hereby authorize the Farifield YMCA to charge the account listed below

on the 20

of each month for monthly tuition fees due as payment for child care services. I understand

that I must provide thirty days written notice if I wish to discontinue service.

I authorize my bank to honor pre-authorized Electronic Funds Transfers (or credit card charges) against

my account for child care payments as indicated below. When the bank honors the EFT or credit card by

charging my account, such transfer shall constitute notice of payment due and my receipt for the

payment. Should any preauthorized EFT or credit card not be honored by said bank when received by

them, then it is understood that the payment is to be made by me in the amount of said payments plus a

return fee of $20. It is further understood that if such a payment is not honored by the bank of credit

card institution, then the YMCA, at its discretion, may submit the amuont due for payment on a future

date.

Please choose from the following options. (Signature is required to process.)

□ I choose to utililze the EFT payment (direct debit from my Checking □ Savings □)

BANK Name _________________________________________ Name on account_____________________________________

Routing/transit Number_________________________________ Account number________________________________

Credit Care Type: Visa □ Mastercard □

Card Holders Name_______________________________________

Account Number_______________________________ Expiratino\\on Date___________________

Authorized Signautre_____________________________________ Date_____________________

Financial assistance is available to those who qualify. Applications are due by the 1

of the previous

month of desired care. If this deadline is not met, you may be asked to pay the current month in full.

FAIRFIELD YMCA

841 Old Post Road, Fairfield, CT 06824

P 203 255 2834 F 203 259 7744 W

Child Care Payment Authorization Form