Student's Name

Parent's Name (if under 18)

Email Address

Credit Card Number (please note we do not accept American Express)

Expiry Month
Month123456789101112

Expiry Year
Year202220232024202520262027202820292030203120322023

I give my permission for any missed fees to be charged to the card provided

I understand that my account will be charged every fortnight on Tuesdays from now until I provide written notice via email to cancel my direct debit