Authorization for Direct Payment

Here's how the Direct Payment Plan works:
You authorize regularly scheduled payments to be made. Your payments will be made automatically each session throughout the class season. Proof of payment will appear on your account. If we have an e-mail address for you, you'll receive an e-mail notification any time a payment is processed. The authority you give to automatically charge your payment information on-file will remain in effect until you notify us in writing to terminate the authorization. If for whatever reason, payments cannot be processed to your payment information on-file and your account balance remains overdue, your enrollment in classes will be cancelled.

All you need to do is:
  1. Mark the box next to the plan you'd prefer
  2. Enter payment information
  3. Sign, date, and return the completed form to the office
  4. Notify the office any time your payment information changes

Automatic / Recurring Payment Plan

I authorize Dance Connection to initiate electronic payments for the balances due on my Dance Connection account.
I understand that payments will be automatically made throughout the year for any balance due on my account. I understand that the payment amounts may vary as classes are added/dropped and as other charges/payments are applied to my account.

Payment Information:

Credit Card Type:
Card Number:
Expiration Date:

Account Holder's Name: _____________________________________________________

Signature: ________________________________________________

Date: __________________


NO Automatic / Recurring Payment Plan

I acknowledge that I am responsible to make timely payments of my balances due on my Dance Connection account.
I further acknowledge that if my payment is not received on or before the due date, I authorize Dance Connection to initiate electronic payments for any balances due on my account PLUS an administrative late fee of $5.00. Payments will be processed with the payment information on-file at Dance Connection.

Payment Information:

Credit Card Type:
Card Number:
Expiration Date:

Account Holder's Name: _____________________________________________________

One Time Payment Amount (if any): __________________

Signature: ________________________________________________

Date: __________________