2026-2027 Tuition Bank Debit Authorization Form

2026-2027 Tuition Bank Debit Authorization Form
Payer/Account Holder Information
Name of Parent or Person Responsible for Tuition Payment (Name as it Appears on Bank Account) - First Name
Name of Parent or Person Responsible for Tuition Payment (Name as it Appears on Bank Account) - Last Name
Name of Parent or Person Responsible for Tuition Payment (Name as it Appears on Bank Account) - First Name
Name of Parent or Person Responsible for Tuition Payment (Name as it Appears on Bank Account) - Last Name
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Student Information
Student #1 First Name
Student #1 Last Name
Student #1 Class
Student #2 First Name
Student #2 Last Name
Student #2 Class
Student #3 First Name
Student #3 Last Name
Student #3 Class
Student #4 First Name
Student #4 Last Name
Student #4 Class
Tuition Total
Bank Account Information
Bank Name
Routing Number
Account Number
Account Type
Please upload a copy of a voided check. Alternatively, please write VOID on a check and "Take Photo" below.
Take Photo
Signature and Date
Signature
Date

MonthDayYear
Date
Should be Empty:

Signature and Date