2015 AAU Basketball Payment Options

Child(ren)’s Name:_________________________________________________ Parent’s name:_____________________________________________________

PAYMENT METHOD:

___I will pay IN FULL by 1st Practice.

___I would like to set up a monthly bank draft.

4th-8th Grade: Drafts on 3/15, 4/15, and 5/15

___ I want to apply for Financial Assistance

and/or set up an individual payment plan.

Maximum financial assistance provided is 50%.

9th – 11th Grade: Drafts on 4/15, 5/15, and 6/15

BANK DRAFT INFORMATION: VOIDED CHECK REQUIRED

Full Name of Bank

___________________________________________________________

Bank Address – City, State and Zip Code

____________________________________________________________

Transit Routing Number

__________________________________________

Account Number

__________________________________________

I authorize you and the financial institution listed to initiate electronic Debit entries to my account to be payable to the order of the La

Crosse Area Family YMCA. I agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and

signed personally by me. The authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree

that you shall be fully protected in honoring any such check. I further agree that if any such check be dishonored, whether with or without

cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the

forfeiture of membership.

_____________________________________________________________________________

Signature Date

CREDIT CARD DRAFT INFO:

AMERICAN EXPRESS___

MASTER CARD____

VISA_____

DISCOVER____

Number_______________________________

Exp Date_______________

3 Digit Security Code (Back of Card) __________

Name on Credit Card_____________________________________________________________

Address of Credit Card Holder_________________________________________________

I authorize you and the financial institution listed to initiate electronic Debit entries to my account to be payable to the order of the La

Crosse Area Family YMCA. I agree that your rights in respect to each such check shall be the same as if it were a check drawn on you and

signed personally by me. The authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree

that you shall be fully protected in honoring any such check. I further agree that if any such check be dishonored, whether with or without

cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in the

forfeiture of membership.

_______________________________________________________________________________________________________

Signature Date