ECC Payment Form

FAMILY INFORMATION

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Email Address

Child's Name

PAYMENT

Which program are you signing up for?

Early Care (8-9am) - $22After Care - $35Full Morning Drop-In (9am-12pm) - $100Something else.

Amount to be charged:

Please specify what you are paying for:

e.g. Tuition, Enrichment, Tot Shabbat, Donation, etc.

PAYMENT METHOD

How would you like to pay your bill?

Credit Card (includes 3% fee)ACH (Direct Bank Debit - No fee)

CREDIT CARD INFORMATION

To help defray some of WHC's credit card processing costs, a 3% fee has been added to your credit card payment. Please note that ACH payments do not include this fee.

Fee Amount

Grand Total

First Name on Card

Last Name on Card

Credit Card Number

Expiration Month

Expiration Year

CVV

Billing Street

Billing City

Billing State

Billing Zip Code

ACH INFORMATION

Bank Account Type

CheckingSavings

Bank Name

Account Holder's Name

Bank Account Number

Bank Routing Number

Different billing address?

Billing Street

Billing City

Billing State

Billing Zip Code

Publicly Hidden Fields

Payment Section

Hide Payment Info

Hidden

Portal Pre-Fill Fields

Account ID

Contact ID

Outreach/Event Pre-Fill

OutreachID

DesignationID

Auth.net Connector Billing Info

Gateway Address

Gateway City

Gateway State

Gateway Zip

Gateway Totals

Gateway Quantity

Gateway Amount

Click SUBMIT only once to avoid being charged multiple times.

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