PAYMENT INFORMATION FORM
Last Name
Address
First Name
City/State/Zip
Phone (Home) (Work)
Membership #
Scholarships
r I am not a Weinstein JCC member
After-Care (5:00 - 6:00PM)
r I am interested in scholarship information
For Camp Hilbert and Specialty Camps only; does not apply to
12-month families.
Select all weeks that after-care will be utilized at $30 per week.
Deadline for scholarship applications is April 19, 2019
Scholarship does not apply to Specialty Camps.
Payment Options
Payment Choice:
r Credit Card
r Check
(Cell)
r Week 1 r Week 4 r Week 7 r Week 10
r Week 2 r Week 5 r Week 8 r Week 11
r Week 3 r Week 6 r Week 9
r Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT)
Pre-authorized debit on the 15th of each month from your checking
account. Your first monthly payment and voided check will be required
to set up this option.
Credit Card
Please complete the appropriate form with credit card number,
expiration date, preferred process date and signature. (Pre-authoriza-
tion from your VISA, American Express or MasterCard monthly.)
Authorization Agreement for Pre-Arranged Payments (Debits)
I (We) authorize the Weinstein JCC to initiate debit entries to my (our)
checking account maintained at the bank named below, herein after
called Bank. r Visa
This authority is to remain in full force and effect until Bank has received
written notification from me (or either of us) to its termination in such
time and in such manner as to afford Bank a reasonable time to act on
it. A customer also has the right to question Bank about any debit entry
by notifying Bank no later than 60 days after Bank sends a statement
to customer containing the entry. Bank will handle all such questions
in accordance with its procedures and the requirements for resolving
errors found in Regulation E issued by the Federal Reserve Board. # of Months _________ Start Date (must begin by June)
# of Months _________ Start Month (must begin by June)
r Mastercard
r American Express
Preferred Process Date (15th, 22nd, or 30th)
First Name
Last Name
Credit Card #
Exp. Date ______________________ Security Code
Signature
S.S.#
Bank Name
Signature
Please staple voided check to the top of this page
r I wish to contribute to the Scholarship Fund to help children
in need attend our life-enriching camps
Contribution Amount for Scholarship $
After-Care Fees
(For Hilbert/Spec.
Camps only)
Contribution
Amount
for Scholarship $
Camp Hilbert Fees $
Specialty Camp Fees $
Camp Ganim Fees $
Voices Together Fees $
Deposit:
$25 per week / per child – $
Total Balance Due by June 1, 2019
Total Fees Less Deposit
30
Office Use Only: Member # ______________________
$
Batch # ______________ Date Received _______________ Date Entered _______________