Quick Pay/EFT
AM/PM
Change Form
Childs Name: _________________________________ Home Phone # __________________
Parents Name: ________________________________ Day Time Phone #: _______________
Family Email Address: ___________________________________________________________
Please check one of the following
I would like to stop using Quick Pay/EFT. Make ____________ the
last deduction.
Change the Checking account that I am using.
(Must a t tach a voided check)
Change the credi t card I am using. Please star t using card #
__________________________________________ EXP_____________
My child will be out star t i ng ___________ and return ____________
Please change my weekly payment amount to $_______________
My child's new schedule will be the following, star t i n g __________
Attending
AM M T W TH F $5 a day
PM M T W TH F $9 a day
1st hr PM M T W TH F $5 a day
AM/PM M T W TH F $14 a day or $56 for 5 days
AM/1st hr M T W TH F $10 a day
Date
You are herby authorized and requested, until otherwise instructed, to charge/deduct from the above referenced
account, the weekly attendance fee and any occurring extra fees, such as late pick-up fees. I understand that if
a CREDIT CARD transaction is DECLINED, a courtesy phone call will be attempted at the numbers listed above.
I further understand that I am responsible for payment and I am aware that if the transaction is declined/
unsuccessful and payment is not made by the due date, penalties will be applied and will not be waived. For
EFT participants this will include a “Return Check Fee”. I further understand that the staff reserves the right to
cancel my “Quick Pay”/EFT” account .
I understand that a request to discontinue or change this service must be made in writing 1 week prior
to the stop date, and given to the Site leader or the Community Services office at 8401 W. Monroe Rm
180, Peoria, AZ 85345.
__________________________ __________
Parent/Guardian Signature Date
Date
Date
Date
Site:___________________