All payments for Preschool, Extended-Care, and School Age will automatically be withdrawn. Please complete this enrollment form and attach a voided check (if applicable). See Tuition and Payments in the Handbook for further information.

Automatic Withdraw Authorization

Name of Child: *

Type of Authorization *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Financial Information

Date of First Payment * +

Date of Last Payment +

Frequency of Payment *

Amount of Maximum Payment *

Please debit payments from my *

Routing Number *

Account Number *

* please note that a 3% fee will be added to your tuition payment for all credit and debit card transactions to cover the additional charges HCLP is charged for the use of them.

Card Number *

Expiration Date *

Name on Card *

Billing Address (if different from above) *

Signature *

clear