Auto Withdrawal Form

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Students & Parents
Grace Baptist Church
Amazing Grace Preschool

Home
Students & Parents
Grace Baptist Church
Amazing Grace Preschool

Auto-Withdrawal Form

GRACE BAPTIST CHRISTIAN ACADEMY
1000 OAK HILL AVENUE
ATTLEBORO, MA 02703

Please Enter Family Information

* Indicates required field

Name of Parent/Guardian/Bill Payer *

First

Last

Preferred Phone Number *

Alternative Phone Number *

Email *

Address of Parent/Guardian/Bill Payer *

Line 1

Line 2

City

State

Zip Code

Country

Enter Student Information

Student Name *

First

Last

Student Name *

First

Last

Student Name *

First

Last

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Student Name *

First

Last

I would like to pay for additional students not listed above. *

Yes No

I have read and agree to the terms and conditions listed below. I agree to pay the amount established by the school for the students listed above and realize that if I fail to make a payment by the specified due date such inaction will result in a late fee of $20.00. I understand GBCA may contact me via email/telephone/text when payments are late. Type your name below. *

Terms and Conditions

Late Enrollment: If GBCA does not receive your enrollment form on time, your first payment will be moved forward. GBCA requires you to catch up on any missed payments on your first due date.

Refunds: GBCA does not issue cash refunds. Overpayments will be carried on your account and credited to future tuition payments. In the event you should receive a reimbursement or refund, it must be arranged through the GBCA Business Office.

Refunds: Any payment that is not received by GBCA by your due date is considered late and will receive a late fee.

Dishonored Payments: A fee of $25.00 will be applied to your account for any failed auto-debit and/or failed check payments. Your bank may impose additional fees.

Auto-debit Terms (Applies to auto-debit enrollees only): By signing this enrollment form you agree to authorize GBCA to debit your account on the scheduled dates as described above. You agree that if any such debit is dishonored, for any reason, GBCA shall have no liability for any fees charged to you by your financial institution. This authority will remain in effect until GBCA receives your written instruction to cancel auto-debit services.

Delinquent Accounts: All students that are more than two (2) months in arrears of their tuition will not be allowed to attend class until the account is brought up to date. The Principal and School Board will be notified of all delinquent accounts.

All outstanding monies owed to owed to the school must be paid before the student may begin the next school year. A senior will not receive his/her diploma until all outstanding monies have been paid.

Amendments: By signing this enrollment form you acknowledge and agree that such terms and conditions may be amended from time to time by GBCA and you will be notified of such amendments in writing.

GBCA Privacy Policy: We do not disclose any personal information about our families to anyone, except as permitted by law. GBCA has adopted numerous procedures to protect the confidentiality of school and family information.

Student Grade *

I authorize GBCA to automatically debit my monthly payments from the below provided account *

Checking (please attach a voided check Savings Other

Routing Number *

Account Number *

Please Charge My: (VISA paid in school office ONLY) *

Amex Discover Mastercard

Debit/Credit Card Number *

Expiration Date *

3 Digit Security Code *

A 3% convenience fee applies to credit/debit card payments.

I understand that my bank account will be withdrawn from on the 20th of each month unless specifically stated otherwise. *

Yes No

Please indicate which day before the 20th you would prefer to have money withdrawn. *

Submit

508-222-8675