On-Line Payment Update Form | The Adventure Club

Please select how your payment information will be used:*

NOTE: *If you choose ONE-TIME ONLY, you will need to TEXT Casey at 540-200-7877 with the amount you wish to be processed -- Keep in mind Tuition is processed each Thursday for the following week*

One-time ONLY -- Point of Sale transaction
Update & use for future automatic transactions

Submission of this form does NOT automatically debit payment from your account. This form ONLY sends your payment information to the account management team to set up for future auto debits or a one-time point of sale transaction once received.

Child's Name

# of Children Enrolled?*

1st Child:*

First Last

2nd Child:*

First Last

3rd Child:*

First Last

4th Child:*

First Last

Payment Type

Debit Method:*

Credit/Debit Card (Visa or MC Only Accepted)
Checking Account (ACH)

Credit/Debit Card Information:

Name on Card:*

First Last

Credit/Debit Card #:*

CONFIRM Credit/Debit Card #:*

Expiration Date:*

Please enter the month & year in the following format: mm/yyyy

3 Digit Security Code:*

Checking Account Information:

Name on Checking Account:*

First Last

Name of Bank:*

Routing #:*

Checking Account #:*

Billing Address:*

Street Address City State & Zip Code

Phone #:*

Email:*

Debit Authorization Agreement

Charges that may be automatically debited from your credit card or checking account will include the following as applicable:

* Registration fees. (these fees are Non-Refundable)
* Weekly tuition charges.
* Late payment fee of $35.
* Add-On day fees for full days of care $30.
* Add-On day fees for early release & late opening $10.
* Late pick-up fee per our policy (see parent handbook.
* Non-Sufficient Funds fee of $35.
* Early Withdrawal Fee of $50 (min 1 week written notice required).
* Approval for charges submitted via phone or email authorization.
* Negative balance of flex hrs owed at a rate of $9.00 hr.

I agree to comply with The Adventure Club's auto debit/payment policies, and I authorize The Adventure Club to save or process payment by the method I have provided on this form.*
I AGREE

Primary Payers Name:*
First Last

Today's Date*
MM slash DD slash YYYY