Pre-Authorized Debit (PAD) Agreement - Kingston Family YMCA

YMCA ofKingston Paid in Full or Continuous Pre-Authorized Debit (PAD)or Change Information (Bank Account or Credit Card)Welcome, and thank you for choosing the YMCA of Kingston. Please review the followinginformation carefully. By signing this document, you are agreeing to utilize yourmembership in accordance with the policies and operating protocols of our Association.Participants Name(s)Name Last Name Birthdate________________________________________________ M/F ________________________________________________________________________ M/F ________________________________________________________________________ M/F ________________________________________________________________________ M/F ________________________________________________________________________ M/F ________________________Customer (Payer)AddressCityPostal Code Phone #Email(for internal purposes only)Y MDY MDY MDYMDY M DToday’s payment of $____________includes an activation fee (if applicable) of $ ________.Pre-Authorized Debit (PAD) AgreementBy signing this document, I authorize the YMCA of Kingston to debit my bank account / credit card forYMCA membership fees as per the terms and conditions outlined below.I hereby authorize monthly personal Pre-Authorized Debits (PAD’s), in the amount of $___________, tocommence on the 15th of __________________, ______,2020____.I understand that my membershipwill renew ew automatically each year and that monthly payments willcontinue until such time as I cancel mymembership. mbers I also understand that my membership fees mayincrease each year upon renewal and that my monthly payments may therefore increase accordingly. Iwill be notified of any increase at least 30 days in advance of my automatic renewal.I may cancel my membership and revoke my authorization at any time, subject to providing writtennotice to the YMCA of Kingston prior to the first of the month. To obtain a sample cancellation form, orfor more information on my right to cancel a pre-authorized debit agreement, I may contact myfinancial institution or visit www.cdnpay.ca.I have certain recourse rights if any debit does not comply with this agreement. For example, I havethe right to receive reimbursement for any debit that is not authorized or is not consistent with thispre-authorized debit agreement. To obtain more information on my recourse rights, I may contact myfinancial institution or visit www.cdnpay.ca.I am of the age of majority (18 yrs). If applicable, I have the authority to agree to such terms on behalfof any member(s) of my family joining the YMCA.Payer’s Signature (Authorizing Withdrawals)DateEffective Date:Anniversary Date:Type of Membership: Individual Family CoupleMembership Category: Adult Senior F.T. Student(if individual)Y’s Hearts Youth Young AdultSeasonal Student FAPYMCA Strong Kids: At the YMCA, we believe that everyone should be able to participate, regardless of theirfinancial situation. Each year, through generous donations to our Strong Kids Campaign, we provide financialsupport for children and families to participate in a YMCA membership and programs that they would otherwisebe unable to afford.Would you considering making a charitable donation to ourStrong Kids Campaign at this time?Amount: $______________Charitable donation receipt required (amounts over $10)? Yes No

TYPE OF MEMBERSHIPContinuous Membership (Pre-Authorized Debits)A continuous membership can be set up using a VISA or MasterCard account, or an activepersonal chequing account, by providing a credit card imprint or a blank cheque (or bankinginformation form).Monthly debits occur on the 15th of each month; full first month payment is required uponenrollment.Continuous memberships are automatically renewed annually unless you advise us to cancel,in writing, prior to the first of the month._________________Customer’s InitialsA courtesy notice will be mailed to you 30 days prior to your anniversary date which willinclude information about fee changes that may impact your PAD agreement.If you wish to renew as a student member, you must show a valid Full time student I.D. prior torenewal in order to receive the student rate; otherwise, you will be renewed as an adultmember.We must be notified of any changes in banking or credit card information, on, including changeof expiry date, by the seventh (7th) of the month. In the case of a change in bank account orcredit card number, we will require a newvoid cheque/banking e/ban change form or credit cardimprint.Kindly notify us in writing of any change ofaddress, dress, email, etc.Annual Membership (Paid in Full)An annual membership is paid in full at the time eofenenrollment and expires upon the anniversarydate.A renewal notice will be mailed to you 30 days prior to your membership anniversary.To avoid incurring a membership activation fee, you must renew within 10 days of youranniversary date.Kindly notify us in writing of any change of address, email, etc.Cancellation/Medical HoldYour YMCA membership commitment is not locked in and may be cancelled at any time. To cancel we requirethat a cancellation request be submitted, in writing, prior to the first (1st) of the month in which you wish tocancel your membership.When an annual (paid in full) membership is cancelled, a refund is issued based upon the time remaining untilthe expiry/anniversary date. The refund cheque will be mailed/or available for pick-up within 14 businessdays.In the event of an extended (more than one month) absence due to medical reasons, annual (paid in full)memberships may be placed on Hold by contacting YMCA Members Services; your anniversary date willsimply be extended based upon your return date.In the event of an extended absence due to medical reasons, continuous (PAD) memberships should becancelled in writing; we will be happy to waive the activation fee upon your return.Activation FeeThe activation fee is a non-refundable fee which supports our investment in future facility development. Thefee is paid once at the time your membership is purchased, provided you maintain your membershipcontinuously from year to year. A lapse in your membership of more than 10 days will result in the activationfee being re-assessed.The activation fee e is requiredof each adult member (adult, senior, Y’s Hearts) or once per family when a familymembership is purchased.Payment of the activation fee is added d to your initialmembership payment.Returned PaymentsAny returned ed payments (NSF, stopped payment, account closed, declined payment, card on hold, etc.) will besubject to a $25.00 administration fee. Payment of this fee, together with the outstanding payment, is due atthe time of your next visit. Facility access will be suspended until such time as the debt is cleared. Membershipaccounts with two outstanding payments will be cancelled unless payment is received within one week of the2nd returned payment. All outstanding fees must be paid before re-starting a membership or prior toregistering in any YMCA of Kingston program or RKY Camp.Privacy StatementThe YMCA of Kingston is committed to protecting personal information by followingresponsible information handling practices in keeping with privacy laws.Our YMCA uses modern information and communication technologies to support our program andmembership-based activities. Our Privacy Statement covers our YMCA and our website. For furtherinformation, please see our website at www.kingston.ymca.caI, the undersigned, have read and understand the above policies._________________Customer’s InitialsSeasonal Student Membership (Paid in Full)The seasonal student membership has a fixed end date and requires the full membership feeto be paid at the time of enrollment. This membership is non-renewable and offers no refundoptions.Fees paid under this membership are not credited toward annual or continuous membership.The “activation fee” will be waived if purchasing an annual or continuous membership within14 days of the expiration of a seasonal student membership.___________________________________________________________SignatureFOR OFFICE USE ONLY Inv. #:______________ Payer. ID:_______________Staff, please verify, check ( ), and initial:Check 1Acc. number/CC number has been inputted correctly.A void cheque has been attached.Staff _______Staff _____________________Check 2______________