PRE-AUTHORIZED DEBIT FORM

Payor’s Contact Information (the "Payor")

First Name:*

Last Name:*

Address:*

Telephone Number: *

Email Address:*

Child's First Name:*

Child's Last Name:*

Month child will begin Preschool:*

Payor’s Financial Institution (the "Processing Institution")

Institution Name:*

Address:*

Account Number:*

Transit Number:*

Institution Number:*

Attach VOID Cheque:

Attach a picture of a void cheque or direct debit form showing banking account information. If you'd prefer, you can also drop off or mail it.

Payor’s Financial Institution (the "Processing Institution")

Name: Kingsland Community Preschool (KCP)

Address: 505 78 Avenue SW, Calgary, AB T2V 0T3

Telephone Number: 403-258-1308

I acknowledge that this payor authorization (the “Authorization”) is provided for the benefit of the Payee and the Processing Institution and is provided in consideration of the Processing Institution agreeing to process debits against my account, as listed above, (the “Account”) in accordance with the Rules of the Canadian Payments Association.

I will inform the Payee, in writing, of any change in the information provided in this Authorization prior to the next due date of the Pre-Authorized Debits (the “PAD”).

I warrant and guarantee that all persons whose signatures are required to authorize withdrawals from the Account have signed the Authorization below.

I hereby authorize the payee to issue the PAD drawn on the Account for the purpose of funding the preschool childcare provided to my child(ren) or child(ren) placed under my care.

I may cancel the Authorization at any time upon providing written notice to the Payee.

I acknowledge that provision and delivery of the authorization to the Payee constitutes delivery by me to the Processing Institution. Any delivery of the Authorization to the Payee, regardless of the method of delivery, constitutes delivery by me.

The Payee will issue a PAD*:

Please choose one payment option:*

$200 - Monthly (1st of the month September-June**)

$1,000 - Two Payment Plan (June 1 & January 1)

$2,000 - Single Installment Plan (June 1 of the current preschool year)

I consent to:*

$50 - Registration Fee. Within month of registering.

$100 - Cleaning Fee (if no parent volunteers for a scheduled cleaning bee). End of school year (June)

* If you have financing or payment concerns, please speak directly with the teachers.

** June tuition is a pre-payment required before school begins. If registering late, the June tuition will be debited from your account at the time of the first PAD when your child begins preschool.

I acknowledge that the Payee may also charge a $25 Not Sufficient Funds (NSF) fee each time a PAD cannot be fulfilled due to insufficient funds in the Payor’s bank account. The NSF charge will be an additional debit taken at the discretion and convenience of the Payee.

I acknowledge that the Processing Institution is not required to verify that a PAD has been issued in accordance with the particulars of the Authorization, including, but not limited to, the amount, or that any purpose of payment for which the PAD was issued has been fulfilled by the Payee as a condition to honouring a PAD issued or caused to be issued by the Payee on the Account.

Revocation of the Authorization does not terminate any contract for childcare that exists between me and the Payee. The Authorization applies only to the method of payment and does not otherwise have any bearing on the contract for services exchanged.

I may dispute a PAD only under the following conditions:
i) The PAD was not drawn in accordance with the Authorization; or,
ii) The Authorization was revoked.

I acknowledge that in order to be reimbursed a declaration to the effect that either (i) or (ii) took place, must be completed and presented to the branch of the Processing Institution holding the account up to and including 90 calendar days after the date on which the PAD in dispute was posted to the account.

I acknowledge that when disputing any PAD beyond the time allowed in this section that it is a matter to be resolved between me as the Payee, outside the payments system.

I agree that the information contained in the Authorization may be disclosed to the Payee’s bank institution as required to complete any PAD transaction.

I understand and accept the terms of participating in the PAD Plan at Kingsland Community Preschool:

Your name:*

Date:*

This field should be left blank

PRE-AUTHORIZED DEBIT FORM

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