ACTON-BOXBOROUGH COMMUNITY EDUCATION COMMUNITY EDUCATION ACCEPTS VISA, MASTERCARD, DISCOVER, AND AMERICAN EXPRESS

SUMMER DAY PROGRAM, 2017 IF YOU WISH TO CHARGE YOUR CHILD’S SUMMER DAY PROGRAM 2017 TUITION, PLEASE FILL OUT THE FORM BELOW AND FAX (978-266-2540) OR MAIL TO: Acton-Boxborough Community Education Administration Bldg., 15 Charter Road, Acton, MA 01720

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I wish to charge my child’s Summer Day Program tuition.

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I wish to charge my child’s Summer Day Program tuition and Extended Hours tuition. TUITION WILL BE CHARGED ON June 1, 2017 There are no tuition refunds after that date.

CHILD’S NAME: _____________________________________________________

CHARGE TO:

*CARD #:

VISA

M/C

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DISCOVER

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AM EX

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*EXPIRATION DATE: *CID (Security Number) \ (last 3 digits on signature strip for VISA/MC/Discover, or the printed numbers above account # on front of AM EXP)

CARDHOLDER’S NAME (Please print):___________________________________ CARDHOLDER’S SIGNATURE: _________________________________________