Payment Authorization

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PRE-AUTHORIZED PAYMENT AUTHORIZATION (REQUIRED)

Full Name:

Email Address:

Address:

Postal Code:

Phone Number:

Alt. Number (optional):

Child 1 Name (first, last):

Program Location:

Child 2YesNo

Child 2 Name (first, last):

Program Location:

Child 3YesNo

Child 3 Name (first, last):

Program Location:

AUTHORIZATION (REQUIRED)

I understand that each check box within this document constitutes electronic consent in lieu of an original signature on paper.

I authorize KidZinc and my financial institution to begin regular recurring deductions of payment of all charges arising under my KidZinc account as per the KidZinc Fee Schedule and Family Handbook.

I authorize KidZinc to process regular payments for the full amount of KidZinc charges on my account on the first day of each month (or next business day). This authority is to remain in effect until written notice has been received by KidZinc.

I may revoke my authorization at any time by providing 30 days written notice to the KidZinc Head Office.

I have certain recourse rights if any debit does not comply with this agreement. For more information on my recourse rights I may contact my financial institution or visit www.canpay.ca.

I understand that cancelling my pre-authorized payment agreement does not cancel my contract for services with KidZinc or any amount owed. The cancellation only applies to the payment method. I agree to make arrangement with KidZinc to pay any amounts owing following the termination of this agreement.

By entering your name and clicking AGREE below, you are authorizing KidZinc to process payments under the conditions noted above.

Enter your full name:(REQUIRED)

I agree: (REQUIRED)AGREE

SUBSIDY STATUS (REQUIRED) I am approved for subsidy I will be applying for subsidy I do not have subsidy

PAYMENT INFORMATION

Payment Method (REQUIRED):

Account Holder Name:

Financial Institution Name:

Transit Number:

Branch Number:

Account Number:

Card Type:

Name on Card:

Card Number:

Expiry Date: (MM-YYYY)

CONFIDENTIALITY

Payment information provided will be entered into a secure third-party payment processing system. Hard copies will be shredded through a secure third-party company.

By entering your name and clicking SUBMIT, you are authorizing KidZinc to use the above payment information to process all KidZinc fees as per the KidZinc Fee Schedule and Family Handbook.

Enter your full name (REQUIRED):

Enter todays date (REQUIRED):

*Please Note: Registration will NOT be submitted if any required fields have not completed*

*Any fields that are still required will be outlined in RED, ensure you scroll up the form to view any missing fields like the examples below.*