Secure Credit Card Monthly Payment Information Form

Card Holder Name (exactly as on card)

Card Type (Visa, Mastercard, Discover, Amex)

Credit Card Number (no dashes; numbers and spaces only. Ex: 4532 6543 5633 7654)

Expiration Date (Ex. 12/2027)

Billing ZIP Code

Credit Card Verification Code (usually 3 numbers on back of card)

Child's 1. Name 2. Day 3. Time 4. Level; Repeat for multiple children (example Sarah Smith - Monday - 4:30 - Level 1)