AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (Electronic Funds Transfer)

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Please note if you already have an account on file you do not need to fill out another form.

MONTHLY TUITION (not including Aerial)

1 Class a week: $70/month
2 Classes a week: $125/month
3 Classes a week: $180/month
4 Classes a week: $225/month
5 Classes a week: $265/month
6 Classes a week: $300/month
7 Classes a week: $330/month
8 Classes a week: $360/month

9 Classes a week: $390/month

10 Classes a week: $420/month

FAMILY MAX
One Dancer Max: $265/month
Two Dancer Max: $420/month
Three Dancer Max: $540/month

Musical Theatre - $5/Month-added to total tuition (Materials Fee)

Aerial - $70/Month-added to total tuition (Equipment Fee & Limited Class Size)

Email *

Dancer's Last Name *

Dancer's First Name(s) *

I understand and accept the following: *

Allegro Dance Studio has permission to deduct monthly tuition fees from my specified account. Deduction will begin on the 1st of the month and continue each month through June 2025.

I understand and accept the following: *

I understand that a $20.00 NSF will be charged if adequate funds are not available. If this happens, you will be contacted by email. Allegro Dance Studio will not make a second attempt via EFT to collect funds. Account must be made current by paying with check or cash and will include the $20.00 Fee.

I understand and accept the following: *

I understand that I must contact Allegro Dance Studio if I need to change accounts or if I would like to discontinue with “EFT”. This must be done in writing before the 1st of the month for any changes to go into effect that calendar month.

I hereby authorize Chase Bank to initiate entries to my Financial Institution:

Debiting Account - Your Financial Institution *

Name on Account *

Routing Number (from check not deposit slip) *

Account Number *

Amount to be debited per month: *

Signature of Debiting Customer (Please type your Name as Signature) *

Date of Signature *

YYYY

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