CARE Payment Authorization Form

Information

Parent/Guardian Name

Child(ren) Names(s)

Re-order	Child's Name	Weight	Operations
	Child's Name	Item weight

more items

Child's CARE site

Arrowhead

Big Sky

Boulder

Meadowlark

Central Heights

Graff

Highland

West

Payment Method

ACH Automatic Payment

Credit/Debit Card Payment (3% Fee)

ACH Payment Information

Account Type

Checking

Savings

Routing/Transit Number (9 digits)

Account Number

Depository (Bank) Name

CARE Academy Payment Authorized Account Holder Information

Account Holder's Name

Phone Number

Address

City/Town

State

ZIP/Postal Code

Credit/Debit Card Information

There is a 3% processing fee for debit and credit cards!

Card Type

Credit

Debit

Card Number

Expiration Date

Security Code (located on back)

CARE Academy Credit or Debit Card Account Holder Information

Account Holder's Name

Phone Number

Address

City/Town

State/Province

ZIP/Postal Code

Authorization Agreement for ACH or Credit/Debit Card CARE Academy Billing
I hereby authorize United Way of Yellowstone County (UWYC) to initiate appropiate ACH or credit/debit card charges and, if necessary, adjustments for entries made in error, to my account indicated above. This authorization shall remain in effect until UWYC has received written notification of its termination in such time and manner as to afford UWYC a reasonable opportunity to act upon said termination request. UWYC may cancel this agreement at any time upon written notification to the account owner.

Cancellation or account changes must be submitted in writing via e-mail to careacademy@uwyellowstone.org. For questions, please call 406.272.8512.

Authorized Signature

There is a 3% processing fee for debit and credit cards!

Cancellation or account changes must be submitted in writing via e-mail to careacademy@uwyellowstone.org. For questions, please call 406.272.8512.

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