Method of Payment Electronic Form

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CHILD(REN)\'S NAME: *

EMAIL ADDRESS: *

AUTHORIZATION: * I authorize Little Learners Christian Preschool to either initiate debit entries or charge my credit card (depending on the choice I make below) for all tuition and fees. I acknowledge that all transactions must comply with the provisions of the U.S. Law. This authority is to remain in full force and effect until Little Learners has received written notification from me of its termination in such time and manner as to afford Little Learners a reasonable opportunity to act on it.

PAYMENT OPTION: *

AUTO-WITHDRAW: Checking Savings

Routing Number

Account Number

CREDIT CARD:

Credit Card # (Numbers Only - NO DASHES

Expiration Date:

3-Digit Security Code

Billing Zip Code:

FULL DAY PAYMENT OPTION: If registering for the full day option (8:00 a.m.-5:00 p.m.) and you would like to pay weekly, instead of once a month, please check this box.

CHECKS will be accepted for the following situation only: (Shannon will contact you with a total.) Paying for the semester in advance (Must be paid for 5 months minimum and due by August 1 and/or Jan 2 to receive discount.)

SIGNATURE: By typing in your name below, you are giving Little Learners permission to use the payment method indicated above for tuition and all fees, including the Registration Fee. The Registration Fee will be withdrawn/charged immediately upon submission. *

TODAY\'S DATE: * date_range

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