Debit Authorization

I (we) hereby authorize Welch Family Enterprises, LLC  dba

Acros Gymnastics & Dance (Company), hereinafter called COMPANY,

to initiate debit entries to my (our) account indicated below and the

financial institution named below, hereinafter called FINANCIAL

INSTITUTION, to debit the same to such account for (Application).

I (we) acknowledge that the origination of ACH transactions to my

(our) account must comply with the provisions of U.S. law.

___________________________    _________________________

(Financial Institution Name)              (Branch)

______________________________________________________

(Address, City/State, Zip)  

Checking Account  ______________            _______________

                            (Routing Number)        (Account Number)

This Authority is to remain in full force and effect until COMPANY has

Received written notification from me (or either of us) of its termination

in such time and manner as to afford COMPANY and FINANCIAL

INSTITUTION a reasonable opportunity to act on it.

____________________    _______________________     _______

(Account Holder Name)                  (Signature)           (Date)

Student Name

1._____________________3. ____________________              

2._____________________4. ____________________

PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM:

Notice: Payments will be deducted on or about the 1st of each month.

For Office Use Only

Student Name:

  Class        Monthly      Discount       Cost

1. _______/__________/__________/______

2. _______/_________/__________/_______

3. _______/________/__________/________

Student Name:

  Class        Monthly      Discount       Cost

1. _______/__________/__________/______

2. _______/_________/__________/_______

3. _______/________/__________/________

Student Name:

  Class        Monthly      Discount       Cost

1. _______/__________/__________/______

2. _______/_________/__________/_______

3. _______/________/__________/________

Student Name:

  Class        Monthly      Discount       Cost

1. _______/__________/__________/______

2. _______/_________/__________/_______

3. _______/________/__________/________

Total Monthly Charge $_____________

Beginning Date  _____/_____/_____

End Date  _____/_____/_____