2015 – 2016 School Store Charge Form The School Store is pleased to be able to offer billings of the School Store charges in addition to our usual payment methods of cash and check. Please complete this form if you would like your child to be able to charge purchases at the Store. If we do not have an authorization on file, your child will need to be pay by cash or check. AUTHORIZATION TO CHARGE I ____________________________, grant permission to ___________________________, (Your Name) (Student Name) who may charge items from the School Store at Ridgefield Academy. My child can charge up to _______________ per visit. Dollar Amount Mark One: Only School Supplies Only Clothing Any Purchases I agree to pay all charges to my School Store Account upon receipt of my monthly statement. Any accounts past due thirty (30) days will be suspended from future charge purchases. Signature: ________________________________Phone: _________________ Please return this form by mail to 223 West Mountain Road, Ridgefield,
CT 06877 or fax to (203) 894-1810 – Attention – RAPA School Store.