Payment Update Form - ALL Branches

YMCA of Delaware

Payment Information Form

Processed By

Karen Colette Wendy Tiffany Emily Tracey Val Patricia

Processed Date

Notes

YMCA Branch*

Brandywine Central/Walnut Street Western Dover Sussex Bear-Glasgow Middletown

Member Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone*

Member or Facility Access Card Number

Please use this account for the following YMCA automatic billing (check all boxes that apply):*

Membership Staff Membership Camp Childcare Swim Team

Other:

Credit Card

Name as it appears on the card

Bank Name

Account Number

Routing Number

The 9 digit number that identifies your bank found at the bottom of your checks.

Credit Card Authorization Agreement*

I agree to the credit card authorization agreement.

Credit Card Authorization Agreement : The YMCA processes payments to the bank on either the 1st and 3rd Fridays of each month. If we are unable to draft your account for any reason, we will automatically redraft your account on 4th Friday of the month. Bank Draft Memberships will continue until terminated in writing. Five days notice prior to the first of the month of termination is required to change or stop payment on any Bank draft. Rate Adjustments: Rates will automatically be adjusted for the age appropriate membership type the month after the birthday of the membership holder. The YMCA reserves the right to raise rates annually on the first day of January. Please contact the branch for the most current pricing and membership options. Membership Credits & Refunds: Joiner fees are not refundable. Disputes over payments may be requested for a review up to 60 days following the charge to account. After 60 days, no refund or credit will be issued. Approved refunds will be issued as a credit to the members account for future services. Upon signing a hold agreement, it is the responsibility of the member to terminate the membership at the end of the hold cycle to avoid being charged. Refunds will not be issued. If the membership has been terminated, credit will be issued back to the credit card on file. All credit card refunds could take up to 14 business days to process. Approved refunds will be returned to the original method of payment. If a refund by check is required, the process may take up to 6 weeks. No refunds will be issued or waived upon suspension or revocation of membership for violations to the YMCA Code of Conduct or any other violation of the YMCA rules and regulations. Gift Certificates are non-refundable and are valid for one year from date of issue. Program Credits & Refunds: The YMCA will only credit/refund money due to medical reasons with a doctor note. Any credit/refund made after the start of a session will be prorated at the discretion of the Program Director. All group lessons have a minimum enrollment number. Programs with fewer participants may be combined or cancelled. You will have the option of receiving a full refund/credit or switching to another similarly priced program or class.

Membership Payments:

If you had a returned payment, we can also process your credit or debit card payment to keep your membership up to date.

Payment Authorization

I authorize the YMCA of Delaware to process the above payment.

I authorize the YMCA of Delaware to process any outstanding payments for membership fees with the updated account information that I provided.

Authorized By Name

First Name

Last Name

Date MM/DD/YY