2019 / 2020 Rachel D's Dance Autopay Form
Registration Deadline: September 13, 2019
Contact us at (507) 884-9151 or racheldsregister@gmail.com
If you HAVE completed a form in a previous year, and wish to continue using that account information, please enter your name here. If not type N/A and move to the section below. *
Your answer
Updated payment amount for 2019/2020 *
Your answer
New Account: Name and contact number of account owner, and party responsible for payment
Your answer
Dancer (s) Name (s) who's monthly tuition is covered with this payment: *
Your answer
Financial Institution *
Your answer
Type of Account (Checking or Savings) *
Your answer
Financial Institution Routing Number *
Your answer
Personal Account Number *
Your answer
Signature Box: By entering my name in the following box, I give consent for Rachel D's Dance Studio, LLC., to make withdrawals for monthly tuition, on the first day of the month (or first business day of the month) or as disclosed to me beforehand, to cover any future expenses (such as shoes, costumes, etc.) incurred during the 2019-2020 dance season. I understand I am responsible for any fees incurred by Rachel D's Dance Studio, LLC, on my behalf and due to my error that may result from providing an incorrect account no., not informing Rachel D's Dance Studio, LLC, of an account change at least 10 days prior to the pulling of the monthly tuition/assigned fee, or not have adequate funds in the account (or any other necessary reason) *
Your answer
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