HANOVER
THT5HOA4Y0HANOVER YMCA STINGRAY SWIM TEAM
DRAFT AUTHORIZATION FORM
FALL/WINTER SEASON 2016-2017
Child’s Name: ______________________________________________________________________
Parent(s)/Guardian(s) Name: __________________________________________________________
Home Address: _____________________________________________________________________
City: ______________________________State: ____________ Zip: _________________________
Home Phone: (_____) ____________________ Other Phone: (_____) _________________________
I, ______________________________________________________ herby authorize the Hanover
(Please Print Parent/Guardian Name)
Area YMCA to charge my Bank/Credit Card (circle one) account for swim team fees the 15th of the
month from October 2016- February 2017 (first month‘s payment will be taken at registration) in the
method of payment I indicate below:
Checking Account Draft Method of Payment
(Please attach a voided check)
Bank Name: _______________________________________________________________________
Bank Address: ______________________________________________________________________
City: ____________________________________ State: _____________ Zip: _________________
Routing #:______________________________________ Account #:__________________________
Payment of: $_____________________ will be charged on the monthly schedule listed below.
Credit Card Draft
If you would like to draft from a credit card please see Tammy Shore to set up draft.
Draft Schedule
Monthly – drafted the fifteenth of the month (or next official bank day).
PAYMENT CHANGE/CANCELLATION POLICY
I understand that my checking/credit card account will be charged according to the schedule above. I understand that I am
financially responsible for all payments from my account. Should my monthly amount not be honored by my bank or
credit card account for any reason, I understand and agree that a $30 NSF fee will be collected electronically from my account.
I agree to give the Hanover Area YMCA written notification of any change/cancellation of this payment agreement
by the 1st of the prior month for monthly payments. After receipt of written notification, the YMCA will change or stop the
draft payment. In the case of cancellation, I understand that failure to follow this policy will result in continued debts/charges to
my account until written authorization is received. I understand that the YMCA reserves the right to cancel this financial
agreement if at any time my Bank/Credit Card charge is invalid. Therefore, in order for my child(ren)to continue to participate
on the Swim Team, I agree to remit any outstanding fees within 10 days. I have read and understand all the provisions set
forth above.
Parent/Guardian Signature: _________________________________________________ Date: ______________________