Auto Deduct Form - Avalon School of the Arts Electronic Funds Transfer Authorization

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As a duly authorized check signer on the financial institution account identified below, I authorize Avalon School of the Arts to perform scheduled or periodic electronic funds transfer debits and/or credits from my account identified below for payments due or when applicable, apply electronic funds transfer credits to the same. This applies to check by phone payments as well as any other electronic payment. I understand the dollar amount can vary depending on services performed.
Furthermore, if any such electronic debit(s) should be returned by my financial institution as Non-Sufficient Funds (NSF), I agree to pay a returned item fee of $25.
For accounting purposes, all electronic debits will be reflected in the monthly bank statement that corresponds with the financial institution account on file with Avalon.
I understand and authorize all of the above as evidenced by my signature.

Email *

Student Name *

Parent/Guardian Name *

Authorizing Signature *

Today's Date *

YYYY

Choose ONE option: *

I would like my costume fee to be added to my monthly payments.

I would like my costume fee to be deducted in full with my February payment.

Choose ONE option:

I would like my payment deducted from my checking/savings account.

I would like my payment deducted from my credit card.

Clear selection

A copy of your responses will be emailed to the address you provided.

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