Weekly Automatic Payment Consent Form
Name on Account:
____________________________________________________________________________
Student’s Name:_____________________________________________________________
Address:_____________________________________________________________________
City: Zip:______________________________________________________________________
Home Phone:_______________________ Alternate Phone:_____________________________
Email:_______________________________________________________________________
Please Circle:
VISA MasterCard Amex Discover
Credit Card/Debit Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: __ __ / __ __
CVI# Located on back:¬¬__ __ __
Please read and sign the following agreement:
With my signature below, I authorize journey performing arts center, inc or its assignees to initiate debit to the account
indicated above. I understand that my account shall will be automatically be charged on the _____ of each week for
the amount of $________ from ___________to ___________ electronically debit my account for the amount of $__ __.
__ __. I fully understand that i will not receive advanced notice of the bank deduction associated with my child’s
program fees above, and authorize a $35.00 service charge for returned or unpaid drafts from the bank. I am aware
that in the event that outside collections or a legal suit is necessary to enforce payment of the account, i agree to pay
all collections fees, interest and/or attorney’s fees and court costs as may be deemed reasonable. I acknowledge the
above stipulation of this debit agreement and agree to automatic credit card debit (if applicable), and will abide by any
charge that is accrued for insufficient funds.
Signature___________________________________________Date ___________________________
Please Print___________________________________________________________________
Journey Performing Arts Center
1456 Boulevard Ave S.E.
Atlanta, Ga. 30315
Tel: 404-622-2585 * Fax: 404-622-2585 * www.JourneyArtsCenter.org
Name on Account:
____________________________________________________________________________
Student’s Name:_____________________________________________________________
Address:_____________________________________________________________________
City: Zip:______________________________________________________________________
Home Phone:_______________________ Alternate Phone:_____________________________
Email:_______________________________________________________________________
Please Circle:
VISA MasterCard Amex Discover
Credit Card/Debit Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Expiration Date: __ __ / __ __
CVI# Located on back:¬¬__ __ __
Please read and sign the following agreement:
With my signature below, I authorize journey performing arts center, inc or its assignees to initiate debit to the account
indicated above. I understand that my account shall will be automatically be charged on the _____ of each week for
the amount of $________ from ___________to ___________ electronically debit my account for the amount of $__ __.
__ __. I fully understand that i will not receive advanced notice of the bank deduction associated with my child’s
program fees above, and authorize a $35.00 service charge for returned or unpaid drafts from the bank. I am aware
that in the event that outside collections or a legal suit is necessary to enforce payment of the account, i agree to pay
all collections fees, interest and/or attorney’s fees and court costs as may be deemed reasonable. I acknowledge the
above stipulation of this debit agreement and agree to automatic credit card debit (if applicable), and will abide by any
charge that is accrued for insufficient funds.
Signature___________________________________________Date ___________________________
Please Print___________________________________________________________________
Journey Performing Arts Center
1456 Boulevard Ave S.E.
Atlanta, Ga. 30315
Tel: 404-622-2585 * Fax: 404-622-2585 * www.JourneyArtsCenter.org
