White Rock Dance

Credit Card Authorization

School Name   

Student Name    



Type Of Card   


Name on card   

Card number    

Expiration date        CVC Security code  


Billing Address For Card 


City    State    Zip Code   



I  authorizing White Rock Dance to charge the above credit card for tuition, costumes, and other related dance fees. I realize that if for any reason I need to stop dance payments, I must contact Karissa Agnew by email at least 5 days prior to the 1st of the month. All credit cards will be charged on the 1st of each month. *Invoices will be sent home in your child’s take home folder to be sent home by the 20th of each month.

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White Rock Dance https://whiterockdance.com
Signature Certificate
Document name: Credit Card Authorization
Unique Document ID: 402e8b0cc09b534e271bc4fbfb726d7e9902ae01
Timestamp Audit
2015-06-08 03:53:36 CSTCredit Card Authorization Uploaded by Karissa L Agnew - whiterockdance@gmail.com IP