Auto-Charge Enrollment

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First Last

Student 2 Name

First Last

Student 3 Name

First Last

Name

First Last

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Expiration Date (MMYY)*

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Please enter a number from 0 to 9999.

I hereby authorize Miss Maria's Dance, Cheer, Gymnastics to charge my card on the first of each month for the following charges along with a 3% service fee.*

Monthly Tuition, Costume Fees (Due In December), and Recital Fees (Due In April)

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