Child Care Payment Form - YMCA of Northwest North Carolina

Branch Name: _______________________________________________Child Care Payment Form(Please Print)Child’s Name: __________________________________________________ Member ID#. __________________________________________School Attending: ___________________________________ Parent’s Name: ________________________________________________Please note: A one-time $30 registration fee applies to all Before and After School programs.Before and After School Options (Please choose payment method on back)Before School (Monthly rate)o $70 Memberso $80 Potential members5 Day-After School (Monthly rate)o $184 Memberso $224 Potential members3 Day-After School (Monthly rate)o $148 Memberso $180 Potential membersOut of School Day Options (Payment is due at registration)Out of School Days (Daily Rate)o $25 Memberso $40 Potential membersSpring Break (March 28 th , April 1 st –5 th )(6 days for the price of 5)o $125 Memberso $240 Potential MembersCan be purchased individually at the daily rate aboveChildcare is offered from 7:00am-6:00pm onthe following Out of School Days: November 5 th , 6 th , 12 th , 21 st December 21 st , 26 th , 27 th , 28 th January 21 st , 22 nd February 18 th March 28 th April 1 St , 2 nd , 3 rd , 4 th , 5 th

Before and After School Payment Options: (Choose 1, 2 or 3.)1. Walk-in Payment (Can only be paid once monthly on or before the 1 st .)By signing below, I understand that monthly payments are due on or before the first day of the month in which theservice is rendered. I further understand that if I do not make my payment on or before the due date I will becharged a $10 late fee. I understand that cancellations and/or account changes require a 30-day advance notice.Any returned payments will be collected along with applicable processing fees. I also understand that I will needto stop any membership draft independently of the child care draft if I so desire.Monthly Amount Due: $ _________________________Signature: ___________________________________________________________ Date:________________________________2. Bank DraftFrequency of Bank Draft: (Choose one)Last four numbers of Account to Draft: _________________________________o Once Monthly on the 1 st o Once Monthly on the 15 th o Bi-Weekly (1 st & 15 th )Date of First Draft: _____________________________Monthly Draft Amount: $ ___________________________3. Credit Card DraftPlease check which card you wish to use for your payment:o VISA o MASTERCARD o DISCOVER o AMERICAN EXPRESSName (as it appears on card): ____________________________________________________________________________________________________________Billing Address For Card:__________________________________________________________________________________________________________________________________________________(Street Address) (City) (State) (Zip)Last four numbers of Credit Card: ___________________________________________ Expiration Date: ______________________________Frequency of Credit Card Draft: (Choose one)o Once Monthly on the 1 st o Once Monthly on the 15 th o Bi-Weekly (1 st & 15 th )Date of First Draft: _________________________________ Monthly Draft Amount: $ _____________________________________Draft Authorization Statement: By signing below, I authorize the YMCA of Northwest North Carolina to draft thecost of my child care payment in the amount and on or about the day(s) indicated above. I understand that the bankdraft will begin as stated on this authorization. If I wish to cancel the automatic bank draft or make changes to thedraft account, I will complete a cancellation form or change form that is provided by the YMCA of Northwest NorthCarolina in the membership office or at the Welcome Center. I understand that cancellations and/or accountchanges require a 30-day advance notice. Any returned drafts will be collected along with applicable processingfees as funds are available in my account, which may not coincide with the above elected draft date. I alsounderstand that I will need to stop any membership draft independently of the child care draft if I sodesire. Please verify your draft once it has begun. If you have questions, please call your local YMCA Branch.Signature: _____________________________________________________________ Date: ______________________________