School of Music Bank Account Auto Withdrawal form

School of Music Automatic Bank Withdrawal Authorization Form

I hereby authorize Rosewood Park Alliance Church to initiate automatic withdrawals from my bank account at the financial institution named below for payment of Tuition for the School of Music.

Apple Music- Registration fee: $30.00 (non-refundable), Material Fee: $61.00, Monthly Tuition: $49.30
Music Wonderland- Registration fee: $30.00 (non-refundable), Material Fee: $60.00, Monthly Tuition: $58.65
Junior Music Courses- Registration fee: $30.00 (non-refundable), Material Fee: $113.00, Monthly Tuition: $71.25
Private Lessons- Registration fee: $30.00 (non-refundable). Director will be in touch with you to establish time, teacher, and amount due each month.

Further, I agree not to hold Rosewood Park Alliance Church responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in withdrawing funds from my account.

This agreement will remain in effect until Rosewood Park Alliance Church receives a written notice of cancellation from me or my financial institution, or until I submit a new “Automatic Bank Withdrawal Authorization Form”, subject to providing notice of 30 days, or until the end dated listed below.

Please fill in the following:

Course name (group lessons)/Teacher's name (private lessons) *

Student(s) Name (first and last) *

Parent(s) Name *

Address *

Tip: Street, City, Province, Postal Code

Home Phone

Tip: xxx-xxx-xxxx

Cell Phone

Tip: xxx-xxx-xxxx

The registration fee and the material fee will be withdrawn upon receipt of this form. Once the Music School course begins, equal tuition payments will be withdrawn on the 1st of each month for the duration of the course from the account listed below.

NSF Fees will apply at a rate of $45.00 per NSF Payment, to be added to the next payment.

Banking Information

Name on Account *

Name of Financial Institution *

Tip: TD, CIBC, Bank of Montreal, etc.

Financial Institution Number *

Tip: 3 digit number

Transit Number *

Tip: 5 digit number

Account Number *

Authorization

Name *

Tip: Your Name

By checking this box, I (named above) understand that this is equivalent to my signature for Pre-Authorized Payments to be made to the Rosewood Park School of Music *

I consent

Date *

Tip: Today's date