Required fields are marked with asterisks (*)

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting the KPR Main Office at 330-673-8897. This authorization will remain in effect until cancelled.

Please list the cardholder name:

Please list the last four digits of the card number:

Please list the security code:

Please choose the card's expiration date:

Please list the ZIP code from the card's billing address:

Please select how you would like to be billed:

Monthly

Bi-weekly

Weekly

Please list the first and last names of your children in the program:

Please list your name:

By signing this form, you are authorizing Kent Parks & Recreation to charge the above credit card for the child care services they are enrolled in at either Lil' Learners Preschool or KPR Kidz Club. I understand that my information will be saved to file for future transactions on my account. The complete card number must be called into the office at 330-673-8897 or given in person at our office located at 497 Middlebury Road.

Customer Signature

Clear