CAMPBELLS KIDS CLUB, LLC

CHILD CARE AUTO PAY AGREEMENT

AUTOMATIC MONTHLY CREDIT CARD CHARGE PLAN
CHILD (REN)S NAME: ___________________________________________________________
PARENT / GUARDIAN NAME: _____________________________________________________
ADDRESS: ______________________________________________________________________
PHONE #: ____________________________________

WORK: _________________________

I HEREBY GIVE AUTHORITY TO CAMPBELLS KIDS CLUB, LLC TO CHARGE MY CREDIT

CARD FOR MONTHLY CHILD CARE PAYMENTS IN THE AMOUNT OF $________________ BY
THE THIRD BUSINESS DAY OF THE MONTH. I UNDERSTAND ANY ADDITIONAL FEES
INCURRED DURING THE MONTH WILL ALSO BE CHARGED TO MY ACCOUNT IN THE
SUBSEQUENT MONTH.
PLEASE CIRCLE ONE:
VISA

MASTER CARD / DISCOVER

DINER CLUB INTERNATIONAL

CC # _______________________________________________

JCB

EXP. DATE: ____________________

AMERICAN EXPRESS
CC #: _______________________________________________ EXP. DATE: ____________________
SHOULD I DECIDE TO TERMINATE THIS AGREEMENT OR WITHDRAW MY CHILD (REN) FROM
THE PROGRAM, I AGREE TO NOTIFY CAMPBELLS KIDS CLUB IN WRITING GIVING ONE
MONTHS NOTICE. AFTER RECEIPT OF WRITTEN NOTIFICATION, CAMPBELLS KIDS CLUB
WILL END THE PRE-AUTHORIZED CHARGES AGAINST MY ACCOUNT AND WILL APPLY THE
DEPOSIT TO THAT MONTHS OBLIGATION.
CAMPBELLS KIDS CLUB RESERVES THE RIGHT TO TERMINATE THHIS AGREEMENT
SHOULD THE AUTHORIZED CHARGE TO MY CREDIT CARD ACCOUNT BE DECLINED AFTER
TWO CONSECUTIVE ATTEMPTS.

PARENT / GUARDIAN / CREDIT CARD HOLDERS SIGNATURE

Please send this form to: Campbells Kids Club, LLC
2 Four Corners Road Blairstown, NJ 07825
Tel: 973-271-4058
www.campbellskidsclub.com

DATE