SL]FFIELD ACADEMY - Suffield Academy

FORM rs DUE JULY l5,20ll
SUFFIELDACADEMY
DEBIT CARD FORM
S ffi eld, C onnect icu t 0607 I
Please detach this sheet and fill in all information, Mail the completed form and your deposit by
July 15,Z}II,in order to activate your child's Debit Card Account.
Student's Name
Class of
Spending Restrictions
Pleøse check the appropriate boxes:
Cash Bank tr Unrestricted Use (maximum $50 per day)
Athletics
Unrestricted
Student Activities Unrestricted
Academic
lJnrestricted
Health Center Unrestricted
Maintenance
Unrestricted
tr V/eekly Allowance Amount
(Note: Cash Bank allowance that is not drawn carries over and
accumulates from week to week.)
tr No Cash Withdrawal Allowed
Extraordinary Cash Restricted to parent/guardian confirmation for each request.
Bookstore tr Unrestricted Use
tr MonthlyLimit
Snack Bar
tr Only Cash/Check/Credit Card Purchases Allowed
tr Unrestricted Use
tr Weekly Limit
tr Only CashiCheck Purchases Allowed
Amount Enclosed
(checks payable to Suffield Academy)
Please provide address of person(s) responsible for Student Debit Card Account. Monthly Debit Card Account statements will be sent to this
address:
Name(s)
Phone
Street
E-mail
City State Zip Code
Country
I/we understand that the maintenance of a balance in this account is my/our responsibility and that Suffield Academy will not, without my/our
request, advance funds to cover a lransaction unless there is a sufficient balance in the account.
Signature(s):
Date:
5.20.11 Please do not staple forms