CREDIT CARD PAYMENT AUTHORIZATION FORM

First Name: ____________________________ Last Name: _________________________

Street Address: ____________________________________________________________

City: ________________________________ State: ________ Zip:____________________

Preferred Contact Number: _________________ Additional phone number:____________

Credit Card Number: ________________________________________________________

Exp. Date: ________________ Name on Card: __________________________________

1)Name of Program: __________________ Monthly amount to be charged: _____________

(First and Last Name of Child, if applicable): _____________________________________

2)Name of Program: __________________ Monthly amount to be charged: _____________

(First and Last Name of Child, if applicable): _____________________________________

3)Name of Program: _________________ Monthly amount to be charged: _____________

(First and Last Name of Child, if applicable): _____________________________________

Your card will be charged the 1^st-10^th of each month

Additional Notes: ____________________________________________________________

I authorize the SJCC to charge my credit card each month tuition and fees:

Printed Name:____________________________ Signature: _______________________

Membership Number: ___________________________________________

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TUITION PAYMENT PREFERENCE

[Form must be submitted with enrollment registration]

I would like to make the following arrangement for tuition payments:

Monthly payments_____________[due by the 10^th of the month]

Quarterly payments____________[payable Sept. Dec. Feb. April]

Charge my credit card [select one] MONTHLY/ QUARTERLY

[Credit card authorization on reverse side]

Other arrangements will be considered. Contact our Membership Director at 377-8803 ext. 236 for assistance.

_______________________________________________________

Child's first name___________________ Last name_________________

(please print)

Your first name_____________________Last name_________________

(please print)

Signature____________________________________Date___________

Membership Number__________________________

JCC office will provide

2565 Balltown Rd. 518 377-8803