EFT Authorization Form
For your convenience you are able to set up monthly recurring draft payments to pay for YMCA programs.
•If changes are made to the information listed below, immediately contact your YMCA branch to update your information. •A $25.00 service charge will be assessed by the YMCA for any draft returned as uncollectible. •Draft payments must be canceled in writing one month prior to the final draft. •YMCA of Honolulu Withdrawal and Refund policy applies to all withdrawals/cancellations.
Participant's First Name
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Participant's Last Name
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List Program(s)
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Account Holder First Name
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Account Holder Last Name
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Phone
Phone
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Email
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Address
Address
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Street Address
City
State
Postal / Zip Code
Select Payment Type
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Select Payment Type
Checking
Savings
Credit Card
Financial Institution
Routing Number
Full Account Number
Exp Date (MM/YY)
I authorize the YMCA of Honolulu to draft monthly payments from my account with the financial institution named above or charge the credit card above for payment of fees.
Draw your signature into the box below.
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Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.