Credit Card Authorization Form

Temple Torat Emet uses an automatic credit card processing system. Credit cards are processed on the 10th of every month. This is a mandatory form for all families enrolled in the Wiston Family Torah Tots Early Childhood Learning Center.

Parent Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Payment Selection
This form allows Wiston Family Torah Tots ECLC to automatically do one of the following:
Please choose one below:*
There is a mandatory 3% convenience fee on all credit card payments. Choosing a credit card payment option authorizes your consent to this fee.
- I hereby authorize Temple Torat Emet to charge my credit card, listed below, on the 10th of each month starting on July 10, 2020. I hereby authorize this automatic charge for my child(ren)'s tuition for a total of 9 equal payments with the last charge to be placed on March 10, 2021.
- Please charge the tuition to the card below in full on July 10th, 2020 and apply the 5% Early Bird Discount.
- I am choosing to pay my monthly bill by check. I understand that in the event my tuition payment is not received by the 10th of the month, I will incur a late fee of $25.00.
Card Information
Card Type*
- Visa
- Master Card
- Amex
- Discover
Card Number*
Expiration Month*
Expiration Year*
Security Code*
- Same as above?
Cardholder Address*
Street Address Address Line 2 City State ZIP Code
Cardholder Phone*
Relationship of Cardholder to Student*
Name of Student*
First Last
Parent's Name*
First Last
Cardholder Signature*
Cardholder's Name*
First Last

Credit Card Authorization Form

Parent Information

Payment Selection

Card Information