Auto Draft Enrollment Form

Number of Students*

Student Name

First Last

Student 2 Name

First Last

Student 3 Name

First Last

Name

First Last

Email

Billing Address*

Street Address Address Line 2 City State ZIP Code

Bank Name*

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Account*

Checking
Savings

Check Routing Number*

See picture below for reference.

Check Account Number*

See picture below for reference.

I agree to have the following fees deducted from my account.*

Monthly Tuition, Costume Fees (With December Tuition), and Recital Fees (With April Tuition)

I hereby authorize Miss Maria's Dance, Cheer, Gymnastics, hereinafter called COMPANY, to initiate debit entries to my account indicated above and the financial institution named below, hereinafter called DEPOSITORY. This authorizationis to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.*

I agree

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