Payment Agreement Plan

Payment Arrangement Planner Signed Authorization

TEXAS XTREME CHEER Recurring Payment

Membership/Class Payment Information
Athlete Name
Parent Name

First Name Last Name
Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
example@example.com
Monthly Tuition
Payment Arrangement Details Payments will be processed on a schedule specified in the details below.
Recurring Tuition Charge Amount
Monthly Tuition Fee
Cheerleading Fees

Option #1 or Option #2
Frequency Option #1 - Six Payments OR Options #2 - Nine Payments
Number of Payments
Recurring Charge Amount
amount based on the Option you choose
Banking Account Information - Name of Bank
Routing Number
Account Number
TEXAS XTREME CHEER Credit Card / ACH Account Charge Authorization

By completing and signing this form, you authorize regularly scheduled charges to the provided Credit Card / ACH Account. You will be charged based on the
the schedule outlined in this agreement, and proof of payment will be sent to the email address provided.

You understand that this authorization will remain in effect until the scheduled end date, or until you cancel the recurring payment, whichever comes first. If the
above noted periodic payment dates fall on a weekend or holiday, you understand that the payment may be executed on the next banking business day and that
because this is an electronic transaction, these funds may be withdrawn from your account as soon as the above noted periodic transaction dates.

To cancel or make changes to this agreement, contact TEXAS XTREME CHEER at. If the amount of your payment or payment schedule changes, we will notify you at
least 10 days before the payment date.

I authorize TEXAS XTREME CHEER to charge/debit my provided account for payment of Membership/Class Payment based on the amount and schedule details
provided above.

TEXAS XTREME CHEER Credit Card / ACH Account Charge Authorization
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Monthly Tuition

Cheerleading Fees