Payment Update Form

Please select the GAC location your family is enrolled at:*

Christiansburg Grace-A-Child USA Academy
Radford Grace-A-Child USA Academy

Please select how your payment information will be used:*

NOTE: *If you choose ONE-TIME ONLY, you will need to TEXT Casey at 540-200-7877 with the amount you wish to be processed -- Keep in mind Tuition is processed each Thursday for the following week*

One-time ONLY -- Point of Sale transaction
Update & use for future automatic transactions

Submission of this form does NOT automatically debit payment from your account. This form ONLY sends your payment information to Casey, our Accounts Specialist, to set up for future auto debits or a one-time point of sale transaction once received.

Child's Name

# of Children*

First Child

First Last

Second Child*

First Last

Third Child*

First Last

Fourth Child*

First Last

Payment Type

Debit Method*

Credit/Debit Card (Visa or MC Only Accepted)
Checking Account (ACH)

Credit/Debit Card Information:

Name on Card*

First Last

CONFIRM Credit/Debit Card #*

Expiration Date*

If your card only shows the month/year, then for the "day" you can just enter the last day of that month.

3 Digit Security Code*

Checking Account Information:

Name on Checking Account*

First Last

Name of Bank*

Routing #*

Checking Account #*

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone Number*

Email*

Debit Authorization Agreement

Charges that may be automatically debited from your credit card or checking account will include the following as applicable:

* Registration fees. (these fees are Non-Refundable)
* Reservation fee of $100.
* Bi-Annual Supply Fee $50.
* Weekly and Monthly tuition charges.
* Late payment fee of $35.
* Late pick-up fee per our policy (see parent handbook).
* Non-Sufficient Funds fee of $35.
* Early Withdrawal Fee of $50 along with tuition (min 4 week written notice required).
* Approval for charges submitted via phone or email authorization.

I agree to comply with Grace-A-Child's auto debit/payment policies, and I authorize Grace-A-Child USA Academy to save or process payment by the method I have provided on this form.*
I Agree

Primary Payer's Name*
First Last

Today's Date*
MM slash DD slash YYYY