Common Contracts
2 similar Child Care/Before and After School Pre-Authorized Payment Agreement contracts
Child Care/Before and After School Pre-Authorized Payment AgreementChild Care/Before and After School Pre-Authorized Payment Agreement • January 23rd, 2020
Main Contact First Name Last Name Birthdate (DD/MM/YY) Gender: Male Female Not Specified Residency Information Street Address City Postal Code Home Telephone Cellular Telephone Business Telephone Email Address Family Information (Family/Group Memberships Only) Name (Incl. last if different from above) Gender Birthdate (DD/MM/YY) 1. 2. 3. 4. 5. Emergency Contact Information Full Name Relationship Phone Number Payment Authorization *Note Only one payment account may be indicated. No split payments.* Account Holder First Name Account Holder Last Name Account Holder Address (If different from above) Payment Type: Visa Mastercard American Express Bank Account (Attach Account Info/Void Cheque)Last 4 Digits of Card: Expiry: Payment Date: All Childcare payments are withdrawn on the 1st of each month. Monthly Payment Amount $ GST (if applicable) $ Total $
Child Care/Before and After School Pre-Authorized Payment AgreementChild Care/Before and After School Pre-Authorized Payment Agreement • January 23rd, 2020
Main Contact First Name Last Name Birthdate (DD/MM/YY) Gender (Circle) Male / Female / X Not Specified Residency Information Street Address City Postal Code Home Telephone Cellular Telephone Business Telephone Email Address Family Information (Family/Group Memberships Only) Name (Incl. last if different from above) Gender Birthdate (DD/MM/YY) 1. 2. 3. 4. 5. Emergency Contact Information Full Name Relationship Phone Number Payment Authorization *Note—Only one payment account may be indicated. No split payments.* Account Holder First Name Account Holder Last Name Account Holder Address (If different from above) Payment Type: Visa Mastercard American Express Bank Account (Attach Account Info/Void Cheque)Last 4 Digits of Card: Expiry: / Payment Date: All Childcare payments are withdrawn on the 1st of each month. Monthly Payment Amount $ GST (if applicable) $ Total $
