Preschool Dance Payment Form

Order Information

Company name:  
Customer ID:
First name*:   Last name*:
Phone:   Alt phone:
Email:   Alt email:
Student First/Last Name*:
Student Date of Birth*:
Preschool/School Name*:
I understands all auto payments are due on the 1st of each month.*:
I understand my card will be billed on the 1st of every month on recurring charges.*:
I understand if payment declines on recurring charges a $5.00 fee is assessed. *:
I understand a 15 day business notice is mandatory for program cancellation. TERMS page on website*:
I understand if payments are not received by the 4th a $15 late fee is assessed on accounts*:
I understand students are not permitted to attend class with an outstanding balance. *:
I understand a 5 day notice will be sent as a reminder for upcoming payment to email on file.*:
I have completed and signed the enrollment form with all signatures. *:
I understand my card on file can be changed on Dazzle's TERM page.*:

Payment Information

Invoice number:
Payment amount:
Payment date:

Choose Payment Type:

Credit card accounts (optional)
Card type*:
Card number*:
CVV2 Code*:
Expiration date*:
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Set as default account:
Credit Card
Credit Card

Billing Address

Address 1*:
Address 2:
ZIP/Postal Code*: Help

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Terms and Conditions

Dazzle Creative Dance and Movement Inc
3729 S. Hickory Ridge Mall
Suite 480 Memphis, TN 38115
(901) 300-0547

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