Credit Card Authorization Form Payment Authorization Form Student Name * Primary Contact Email Address * Phone * (###) ### #### Recurring Charges * You authorize monthly scheduled charges to your Credit Card on the 1st of every month. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your Credit Card Statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 24 hours prior to the payment being collected. Material Fee: $200 (charged July 15th) 2024-25 Pre-K4 & Kindergarten Enrichment (1st of month) 2 days per week = $350 3 days per week = $525 4 days per week = $700 5 days per week = $875 I agree Billing Details Billing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Credit Card * Visa MasterCard AmEx Other Cardholder's Name * Credit Card Number * Expiration Date * CVV * Signature * I authorize Level Up Academy to charge my credit card for monthly tuition. Date * MM DD YYYY Thank you!
