Gingham Giraffe Credit Card Authorization Form

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This form authorizes automatic payment of tuition fees. Additional services above $75 can be charged on request. The authorization will remain in effect until canceled. Please note: an annual one-time processing fee of $25 will be applied upon receipt and again at the time of annual registration.

I authorize The Gingham Giraffe Preschool to charge my credit card for agreed upon services. I understand that my information will be saved to file for future transactions on my account and that receipts will be sent via email to my preferred email address, below. If I need an itemized receipt, I will request one.

Child's Last Name *

Child's First Name(s) *

Name as it appears on Credit Card *

Card # *

Expiration Date (MM/YYYY) *

Security Code *

Zip Code *

Parent Name/Electronic Signature *

Email Address *

Submit

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