Atlantic Arts Payment Authorization

Credit/Debit Card Authorization Form

I/we hereby authorize Atlantic Arts Academy to initiate credit/debit entries (withdrawals) from my/our credit card account for credit to the below-named account on the 1^st day of each month in the amount of $ ________ beginning the __________ day of __________, 2008.   I further authorize a registration fee of $45 for individual student and $60 for family to be charged to my account upon registration as well as a $25 costume deposit for any class that is participating in the year end dance productions.  I further authorize and understand that costume balance payments will be charged to my account on September 1^st, October 1^st, and November 1^st, a total of $100 (including costume deposit) for each class that a costume is needed.  I understand that tuition is non-refundable.  I further understand that costume deposits are non-refundable after December 1^st.

This authority will remain in effect until I/we notify Atlantic Arts Academy in writing by filling out a withdrawal form provided at the front desk in the first week of the month.  I understand that there is a 30 day notice required for all classes and that I will be charged an additional month from the time that I withdraw.   I/we acknowledge that the origination of credit/debit transactions to my/our account must comply with the provisions of U.S. Law. 

Credit Card Information (Circle One):    MasterCard, Visa, Debit Card

Card # ____________________________________________________     Exp Date: _______________

Security Code #: ____________

Name On Card: _______________________________________________________________________

Billing Address: _______________________________________________________________________

City_____________________________________    State______   Zip Code _______________________

Signature of Account Holder : _____________________________________________________________

Name of Account Holder:  ________________________________________________________________

(Please Print)

Cash/Check Payment In Full

(Non - Refundable)

Check #: ______         Cash: _____                                        Amount Paid: $ _________ (including 10% Discount)

I understand that by paying my full tuition by check or with cash that I receive a 10% discount but the tuition is non-refundable.  I further understand that although tuition will be paid in full I must still have a credit card as backup on my account for incidentals and monthly costume payments. 

(Please fill in the information above regardless if you are paying by cash/check or credit.  Thanks.)

Signature of Account Holder : _______________________________________       Dated: _________________

Atlantic Arts Academy * 6743 W. Indiantown Rd. - #34 * Jupiter, FL * 33458 * 561-575-4422