Childcare Services Payment Authorization Form
Parent/Guardian Information
Full Name
Phone
Address
Email
Child(ren) Information
Child(ren) Name(s)
Payment Details
Amount
Payment Frequency
Weekly
Bi-weekly
Monthly
Other
Start Date
Payment Method
Credit Card
Debit Card
Bank Transfer
ACH
Other
Authorization
I authorize the childcare provider to charge my account as indicated above for childcare services.
Signature
Date