14
r Electronic Funds Transfer (EFT)
For Office Use Only: Member # ______________________
Please staple voided check to the top of this page
Signature
Bank Name
S.S.#
# of Months _________ Start Month (must begin by June)
r Mastercard
r American Express
$
$
$
$
–$
Camp Hilbert Fees
Specialty Camp Fees
Camp Ganim Fees
Voices Together Fees
Deposit:
$25 per week / per child
Total Balance Due by June 6, 2014
Total Fees Less Deposit
$
Contribution Amount for Scholarship
Signature
Exp. Date ______________________ Security Code
Credit Card #
Last Name
First Name
# of Months _________ Start Date (must begin by June)
Preferred Process Date (15th, 22nd, or 30th)
r Visa
Please complete the appropriate form with credit card number,
expiration date, preferred process date and signature. (Pre-authorization
from your VISA, American Express or MasterCard monthly.)
Credit Card
(Cell)
Batch # ______________ Date Received ______________ Date Entered ______________
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.
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.
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.
Payment Choice:
r Credit Card
r Check
Payment Options
Deadline for scholarship applications is April 14, 2014. Scholarship does not apply to specialty camps.
r I am interested in scholarship information.
Scholarships
r I am not a member
Membership #
City/State/Zip
First Name
(Work)
Phone (Home)
Address
Last Name
Payment Information