Campus Day Camp

Credit Card Payment Authorization Form

Sign and complete this form to authorize Campus ASP Inc. to make charges to your credit card listed below.

By signing this form you give us permission to charge your account for the amount indicated.

Please complete the information below:

Campus Day Camp Credit Card Authorization

Child's Name *

Full Name *

authorize Campus ASP Inc. to automatically charge my credit card

account indicated below for

Amount *

and to keep this account on file for future charges.

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Account Type *

Visa

Mastercard

Amex

Account Number *

Cardholder Name *

Expiration Date *

CVV2 (3 digit number on back of Visa/MC)

Signature *

Date