Automatic Bank Withdrawal Form

I authorize Miss Kelley’s School of Dance to electronically debit my bank account for all fees, including a non-sufficient fund fee, as provided by law if applicable, between the 1st and 5th business day of the month and will re-occur every month there after.

I understand that I may cancel this authorization by providing written notice to Miss Kelley’s School of Dance at least 5 days prior to the payment due date. This authorization is to remain in full force and effect until Miss Kelley’s School of Dance has received a written notification of withdrawal from classes and all fees have been paid in full. I further understand that cancelling this authorization does not relieve me of the responsibility of paying my fees in full. If withdrawal occurs after October 15th, I understand that I am still responsible for costume payments.

Name

First Name

Last Name

Is the account in our computer system under any name other than the one listed above?

For example, if you are a grandparent paying for dance, etc. Please list the parent name on your dancer's account here at Miss Kelley's.

Student Name

First Name

Last Name

Name of Bank

Routing Number

Account Number