YMCA of the Suncoast School Age Programs
Please PRINT clearly.
School Site:
Unity ID:
Child’s Name: _____________________________________________________________________ Date of Birth: ______/______/__________
Parent/Payer Name: ______________________________________________________________ Phone: ________________________________
Address: __________________________________________________________ City: _______________________ State: _____Zip: ___________
Please CHANGE my child’s School Site:
Please CHANGE my child’s Payment Plan:
Current School Site: __________________________________________
Date Last Attending Current Site: ______/______/__________
Current Payment Plan:
❑ All-Inclusive EFT Plan
❑ Standard Plan
NEW School Site: ___________________________________________
❑ 3 Day Plan
Date First Attending NEW Site: ______/______/__________
Date to END Current Plan: ______/______/__________
NEW Payment Plan:
❑ All-Inclusive EFT Plan
Please CHANGE my child’s EFT (draft) Financial Info:
❑ Standard Plan
Current EFT Payment Type:
❑ Credit/Debit Card (monthly)
❑ 3 Day Plan
Date to START New Plan: ______/______/__________
❑ Bank Account (bi-weekly)
Please complete & sign a new Payment Policy Form
Date to END EFT Type: ______/______/__________
NEW EFT Payment Type:
❑ Credit/Debit Card (monthly)
❑ Bank Account (bi-weekly)
Please CANCEL my child from School Age Programs:
Date Last Attending: ______/______/__________
Date to START EFT Type: ______/______/__________
Please complete & sign an EFT (draft) Change Form
Reason for Cancellation
❑ Found Other Care
❑ Moved
Signature Authorizing Change/Cancel:
❑ Financial
❑ Other ______________________________________________________
Parent/Payer: __________________________________________
Today’s Date: ______/______/__________
Please note: Ten business days of notice is required for any EFT (draft) to be
stopped. Pinellas, Pasco & Hernando County participants: If you have a
current Full membership, your monthly subsidy will expire prior to the next
draft processing.
Y Staff Name: _____________________________________________________
❑ I am submitting this form on behalf of the parent/payer
I spoke to the parent/payer by phone: ❑ Yes
❑ No
If Yes, date: ______/______/__________
❑ I am ending this child’s enrollment due to non-payment
I spoke to the parent/payer by phone: ❑ Yes
Notes:
❑ No
If No, please provide details: