Child Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent Name *

First Name

Last Name

Authorization *

By checking this box, I authorize the JCC of Bayonne to charge my credit card for the non-refundable monthly tuition, non-refundable membership fee and non-refundable registration fee stated on my application and/or any additional fees incurred to my account. (i.e. $25.00 for each declined transaction • $5/minute for late pick-up) I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the JCC of Bayonne in writing of any changes in my account information or termination of this authorization at least 10 days prior to the next billing date. I certify that I am an authorized user of this Credit Card and will not dispute this scheduled transaction so long as the transactions correspond to the terms indicated in this authorization form.

I agree

Card Type *

Visa

Mastercard

Discover

American Express

Cardholder Name *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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