Child Name *

First Name

Last Name

Parent Name *

First Name

Last Name

Authorization *

I authorize the JCC of Bayonne to charge my credit card for all program fees, non-refundable facility fee and non-refundable registration fee stated on my application and/or any additional fees incurred to my account (i.e. $5/minute late pick up fee). I understand that this authorization will remain in effect until canceled in writing and I agree to notify the JCC of Bayonne in writing, one week before due date, of any changes in my account information or termination of this account. I certify that I am an authorized user of this Credit Card and will not dispute this transaction so long as the transaction corresponds to the terms indicated in this authorization form. I understand that there will be a $35 fee for each credit card declined.

I authorize

Card Type *

Visa

Mastercard

Discover

American Express

Card Holder Name *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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