Payment Information Form
Last Name
Address
First Name
City/State/Zip
Phone (Home) (Work)
Membership #
(Cell)
r I am not a Weinstein JCC member
Scholarships After-Care (5:00 - 6:00 PM )
r I am interested in scholarship information For Camp Hilbert and Specialty Camps only; does not apply to
12-month families.
Select all weeks that after-care will be utilized at $25 per week.
Deadline for scholarship applications is April 16, 2018
Scholarship does not apply to Specialty Camps.
Payment Options
Payment Choice:
r Credit Card
r Check
r Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT)
Pre-authorized debit on the 15th of each month from your checking
account. Your first monthly payment and voided check will be required
to set up this option.
Authorization Agreement for Pre-Arranged Payments (Debits)
I (We) authorize the Weinstein JCC to initiate debit entries to my (our)
checking account maintained at the bank named below, herein after
called Bank.
This authority is to remain in full force and effect until Bank has received
written notification from me (or either of us) to its termination in such
time and in such manner as to afford Bank a reasonable time to act on
it. A customer also has the right to question Bank about any debit entry
by notifying Bank no later than 60 days after Bank sends a statement to
customer containing the entry. Bank will handle all such questions in
accordance with its procedures and the requirements for resolving errors
found in Regulation E issued by the Federal Reserve Board.
# of Months _________ Start Month (must begin by June)
S.S.#
Bank Name
Signature
Please staple voided check to the top of this page
r Week 1 r Week 4 r Week 7 r Week 10
r Week 2 r Week 5 r Week 8 r Week 11
r Week 3 r Week 6 r Week 9
Credit Card
Please complete the appropriate form with credit card number,
expiration date, preferred process date and signature. (Pre-authorization
from your VISA, American Express or MasterCard monthly.)
r Visa
r Mastercard
r American Express
Preferred Process Date (15th, 22nd, or 30th)
# of Months _________ Start Date (must begin by June)
First Name
Last Name
Credit Card #
Exp. Date ______________________ Security Code
Signature
r I wish to contribute to the Scholarship Fund
Contribution Amount for Scholarship $
After-Care Fees
(For Hilbert/Spec.
Camps only)
Contribution
Amount
for Scholarship $
Camp Hilbert Fees $
Spe