ACH/Credit Card Enrollment 2020-2021
Please complete the information below: PLEASE NOTE – ONLY ONE FORM PER FAMILY NEEDED – This information on this form will begin pulling 8/1/2020 - or as applicable by registration. If you were previously enrolled in ACH draw and only need to update amounts please skip the Banking Information Section. If you've previously done credit card/debit card invoicing, please fill out as this is a new processor and will auto pull.
Parent/Guardian Name *
Student(s) Name (please include last name if different from parent/guardian): *
I authorize BSOB to charge my account for tuition the 1st day of each month in the amount of $ *
I authorize BSOB to charge my account 9/1/2020 for the yearly registration fee of: ($30 per student no more than $75 per family) in the amount of $ *
I authorize BSOB to charge my account 11/30/2020 for the recital costume fee (ballet & jazz may be combined) of $: (all costume prices are listed in the Tuition and Fees section at bountifulschoolofballet.com) *
I authorize BSOB to charge my account 11/30/2020 for the recital participation fee (ballet & jazz may be combined) of $: (all fees are listed in the Tuition and Fees section at bountifulschoolofballet.com) *
Billing Address, City, State, Zip
Phone #
Email Address *
Bank Name
Routing Number
Account #
Bank City/State
Credit/Debit Card Type
Clear selection
Credit Card Number
Expiration Date
MM
/
DD
/
YYYY
CID
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Bountiful School of Ballet in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Bountiful School of Ballet may at its discretion attempt to process the charge again within 30 days, and agree to an additional $20 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. Clicking "I Agree" acts as a signature and authorizes Bountiful School of Ballet to charge your account for the above items. *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy