Credit Card Authorization Form
2016 - 2017 School Year

Payments for after school care must be made by the 1st of the month. The Boys & Girls Club of Burbank and Greater East Valley will automatically charge your credit card/debit card on the 1st of the month. All inquiries/changes should be directed to Mira Shah who can be reached directly at 818-842-9333 ext 111 or at Please note the following points:

- August Fees will automatically be adjusted since it is half a month and will be charged the week of August 15th
- You must notify our office at least 5 days before the 1st of the month if your child is no longer attending the program. Please note, we cannot hold your spot for you and if you re enroll your child, you must pay the registration fee again. You can provide your notification to Mira Shah via email at or by phone at 818-842-9333 ext 111.
- If you receive a new credit card or your credit card expires, you can use this form to update your credit card information or you can contact our office . If your card is declined and we cannot get a hold of you within 5 business days, then you will be responsible for a $15 late charge.
- We are not responsible for bank charges due to a decline or overdraft.

Is this a new form for 16-17 school year or are you updating your information? *
Please select new if you are signing up for the first time this school year
Member Name *
List all children's names in this box
Your answer
School *
Payment Start Date *
When should auto payment start?
First and Last Name as it Appears on Credit Card *
Your answer
Primary Credit Card Number *
Note: we accept Mastercard, Visa, Amex and Discover
Your answer
Expiration Date (MMYY) *
Your answer
Secondary Credit Card Number
To be used if primary credit card number is declined
Your answer
Secondary Credit Card Expiration Date
Your answer
Amount to be charged monthly *
Note: this amount will be adjusted automatically if approved for financial aid
Your answer
Primary Email Address *
Your answer
Primary Phone Number *
Your answer
Financial Aid?
By checking the box below, I provide authorization to the Boys & Girls Club of Burbank to charge my credit card on the 1st of the month *
Write here if splitting tuition with another party:
Your answer
Your answer
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