Tuition Express – Credit Card Form

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Credit/Debit Card Authorization

I (we) hereby authorize Latchkey Child Services (called "CENTER" in this Authorization) to initiate recurring credit card charges to the below referenced credit card account for the purposes of collecting childcare related payments. I (we) understand that the charges to the below referenced credit card account will be based on charges that are due and payable at the time of the credit card transaction. I (we) understand that this agreement is between myself (us) and the below referenced "CENTER". I (we) authorize CENTER to utilize Tuition Express" to capture, create and transmit all credit card information. I (we) indemnify and hold harmless, Tuition Express from any and all liability resulting from any and all transactions. All disputes will be directed to and addressed by and between CENTER and the below signed cardholder. I (we) understand that to properly affect the cancellation of this agreement, I (we) are required to give CENTER written notice of revocation. A minimum of 5 business days is required to affect revocation.

Acknowledgement*

I agree to the above.

Client Information

Client Number, If Known

Name on Card*

Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Credit Card Number*

Expiration Date*

Tuition Express is normally processed on the first school day of each week. If you require special processing, such as once a month, or other specific processing requirements, please list your request in the field below. This will result in a payment processing fee of $9.95 per payment. If we cannot accommodate your specific request, we will contact you by phone.

Special Instructions

Please enter your full name and current date in the fields below to sign this form.

Signature*

Date*

Record Retention Notice: The childcare provider shall retain all parent (client) authorization forms in a secure location for a period of two years from the date of client withdrawal from the Tuition Express™ program.

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Bank Account Form