Preauthorized Payment Approval Form

Child Information

Child's First Name(s)*

Child's Last Name*

Birth Date*

Home Phone*

Address*

City*

Postal Code*

Parent Information

Last name*

First name*

Address

City

Postal Code

Home Phone

Work Phone

Cell Phone*

Birth Date

Email*

Payer Information (if different that parent)

Last name

First name

Address

City

Postal Code

Home Phone

Work Phone

Cell Phone

Birth Date

Regional Subsidy:

Partial payment? YesNo

Parent Partial per day

Preauthorized Debit Information

Bank/financial institution*

Bank Number*

Transit Number*

Account Number*

Please provide Discovery Point Nursery and Academy with a void cheque indicating the account number and bank/financial institution; Note: If you do not have a chequing account or wish to have the money withdrawn from a different account, you are required to attach the bank verification which provides the following information: Bank Number, Transit Number, Account Number.

Attach the void cheque

Your child care fee of will be debited from your bank account on the 1st day of each month.

By signing this agreement I, , agree to allow the Discovery Point Nursery and Academy

to debit my/our bank account for our child care fees. I understand my monthly fees are directly related to registration and that there will be no reduction of fees due to illness, inclement weather and unexpected centre closure. I understand that child care fees are reviewed on an annual basis and I will be notified 1 month in advance of any fee increase.

I understand and agree that if a payment is returned by my financial institution a second attempt by the bank to recover the funds will be made within 48 hours. If both transactions are returned, this may result in additional fees charged by your bank which will be paid by the parent/payer. In addition to the bank service charges, Discovery Point Nursery and Academy will administer a $50 service charge for any payments returned in advance of any permanent schedule changes by your financial institution.

I understand that I must notify Discovery Point Nursery and Academy in writing 1 month in advance of any permanent schedule changes or cancellation of my child care services.

Signature of Account Holder*

Name*

Date*