WPC CHARGE CARD
AUTHORIZATION FORM
2015-2016
ANNUAL/FULL-YEAR ENROLLMENT: Monday through Friday, school dismissal to 5:45 p.m. for the entire school year.
Full-time tuition is based on the school year divided into ten equal monthly payments. If you wish to have monthly payments of $500
automatically paid via your credit/debit card for the school year, Aug.–June, complete this form and submit along with your child(ren)’s
registration forms. Completing this form will eliminate the need for submitting new registration forms each session. Activity selections
can be made by you or your child(ren), with your permission, directly with the Site Director(s). For activities with limited enrollment
and/or an additional fee, it is your responsibility to inform the Site Director(s) that you wish for your child(ren) to participate. If a
selected activity includes an additional fee, it will be charged to your card on file.
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Cardholder Information:
Please Circle:
Master Card
Visa
Card Number: ___________________________________________________________________
Expiration Date: ______________________________
Cardholder Name: ___________________________________________________________
Phone: _________________________________________
I, _____________________________________________, authorize Westford Recreation, to charge my credit/debit card on the first business day of
each month of the 2015-2016 school year and for any additional activity fees I opt to have my child participate in, if applicable, as well as
any finder’s fees, Early Release lunch fees, or late pickup fees that I may incur. By signing below, I understand to withdraw from annual
registration, I must submit a written notice to the Recreation Department 30 days before the end of my child(ren)’s current session.
Signature: _________________________________________________________________
Date: _______________________________________
FULL-TIME AND PART-TIME ENROLLMENT:
You must keep your credit/debit card information on file for the school year, Aug.–June, with the Recreation Department. You will still be
required to complete and submit registration forms for each session and Special Program in which you wish to enroll. Your card on file
will be used for session tuition, added days/blocks, Special Programs, late/no registration fees, activity fees, finder’s fees, Early Release
lunch fees, and late pickup fees, if applicable. Part-time and full-time participants are eligible to pay the session tuition in two equal
installments with their credit/debit card. First payment will be charged at time of registration, second payment on the first business day
of the following month.
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Child’s Name: ______________________________________________________________________
School: ____________________________________________
Cardholder Information:
Please Circle:
Master Card
Visa
Card Number: ________________________________________________________________
Expiration Date: ______________________________
Cardholder Name: ___________________________________________________________
Phone: _________________________________________
I, _____________________________________________, authorize Westford Recreation, to charge my credit/debit card for session tuition, added
days/blocks and/or Special Programs that I have registered my child(ren) for, as well as any late/no registration fees, activity fees,
finder’s fees, Early Release lunch fees, and late pickup fees that I might incur for the 2015-2016 school year.
Signature: ____________________________________________________________________
Date: _________________________________________
Westford Parks & Recreation
PO Box 2444/35 Town Farm Road
Westford, MA 01886