Charge Card Information

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					                                   YMCA of the Fox Cities
                               Credit Card Authorization Form
                                For FCYST Escrow Accounts

Please fill in the information below to have your credit or debit card charged for your Swim Team
escrow account balance.

Cardholder’s Name_______________________________________________________

Card Billing Address_____________________________________________________

City___________________State___________Zip______________________________

Email _______________________________________

Swimmer’s Name________________________________
Swimmer’s Name________________________________
Swimmer’s Name________________________________

FCYST Escrow account balances will be charged to this card no earlier than a week after escrow
account invoices have been emailed out. This will occur about 4 times during the fall/winter season
and 1 or 2 times over the summer season.

By signing below, I acknowledge that my credit card ending in __ __ __ __ will be charged as
indicated above for any charges in our family swim team escrow account. This process will continue
until I revoke this privilege by submitting a written request.

Signature of Cardholder__________________________________________
Date_______________


Type of Card:        MasterCard            Visa          Discover

Type of Charge:       Credit            Debit

Credit Card#______________________________________ Exp. Date_____________



Please return this form to Silvia Bryson in the Swim Team office at Appleton YMCA, 218 E Lawrence
St, Appleton, WI 54911. You may also drop the form off at any YMCA front desk, if it is sealed in an
envelope marked with Swim Team.

				
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posted:10/3/2012
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