Student(s) Name:___________________________________________________

Cardholder Name:______________________________ Signature:___________________________________

Address:_________________________________________________________________________________

_____________________________________________________
Credit Card Type:
____VISA

____MASTERCARD

____DISCOVER

____AMERICAN EXPRESS

Credit Card: ____________________________________________________________

Expiration Date: _____ / _______

Billing Zip Code:__________

Card Identification Number:(last 3 digits on back of CC or 4 on Front of AMEX)) _________

My daughter/son ________________________________________is a Level ________

Gymnast at Park Avenue Gymnastics, Inc. I am authorizing that my credit card (listed
above) be charged for the monthly team tuition on the 5th of each month, if there is a
balance on my account. I will also let Park Avenue know of any changes to my Credit
Card information.
_______________________________
Signature

Date