EmailMe Form - Elevate Preschool Payment Update

Student Name *

First Last

Additional student/sibling using same payment information.

First Last

Additional student/sibling using same payment information.

First Last

Effective date of payment update *

MM / DD / YYYY

Responsible Party for Billing Purposes *

First Last

Payment Authorization

I authorize Elevate Rock School LLC and the financial institution/credit card company listed below to initiate the following charges:
*Recurring electronic debit entries of my tuition fees
*Past due charges &/or late fees
*Credit/debit entries for errors or price changes
*Other authorized charges such as instrument purchases, field trips, etc. *

I Agree

Financial Institution *

Routing Number (9 Digits) *

Verify Routing Number (9 Digits) *

Account Number *

Verify Account Number *

ACKNOWLEDGEMENT:

By typing your name below you are authorizing monthly automatic payments to Elevate Rock School. Payments will occur on the 28th day of the month for the following month's tuition.

This authority will remain in effect until I have cancelled it.

Responsible Party Signature (typed name)

First Last

Signature - please sign if using a touch screen device

Clear