AUTHORIZATION FORM Child's Full Name* Your Full Name* Your Email* Enter Email Confirm Email Payment OptionsBy completing the form below, Piper Preschool has my continued authorization for charges associated with the contracted school year. I understand that any credit card payment will incur a 3% convenience fee.Payment Type Bank Account Credit Card Bank Name* Account Holder's Name* Account Holder's Phone*Bank Routing Number* Bank Account Number* Account Type* Checkings Savings Name on Credit Card* Credit Card Number* CVV* Expiration Date Phone Number Associated with Card*Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email*