Recurring Payment Processing

ALLSTARS UNITED EDUCATION FOUNDATION

PO Box 21402, San Jose CA 95151. Ph: 1-833-GO-STARS

Recurring Payment Authorization Form: Bank Accounts and Credit Cards

Schedule your payment to be automatically charged to your Bank Account or credit card: Visa, MasterCard or American Express Card. Just complete and sign this form to get started!

Here’s How Recurring Payments Work:

You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. You agree that no prior-notification will be provided.

Please complete the information below:

I

Full Name*

authorize Allstars United Education Foundation to charge my account indicated below for the following

CHECKED ITEMS (PLUS A 3% ADDITIONAL CHARGE IF CREDIT CARD PROCESSING SELECTED) for the Allstars Academy After-School Program,

starting from Aug 17, 2023 (or actual start date if starting later:

MM slash DD slash YYYY

). This authorization will stay in effect until cancelled with a 30-day notice.

*
$545 (or a lesser amount that is the cost of the program for your child) on the 26th of each month for payment of monthly fee for the following month.

Student Name School Name

Billing Address Line 1 Phone

Billing Address - City, State, Zip Email

Select preferred payment type*

Credit Card*
Visa
MasterCard
Amex

Cardholder Name*

Credit Card No*

Expiration Date*

Security Code*

AN ADDITIONAL 3% CHARGE WILL BE ADDED FOR ALL CREDIT CARD PAYMENTS. PLEASE USE OUR ACH CHECK PAYMENT OPTION OR PAY WITH A CHECK TO AVOID THIS CHARGE.

Select Account Type*
Checking
Saving

Name on Account*

Bank Name*

Account Number*

Bank Routing #*

Signature (Initials)*

Date*
MM slash DD slash YYYY

Waiver I hereby instruct ALLSTARS UNITED EDUCATION FOUNDATION ("AUEF") to use the email addresses on this registration for all communications from AUEF to us until we notify AUEF at info@allstarsu.com of an alternate address. If we do not have access to email, AUEF will use the phone numbers on this registration. I hereby give my consent to have an athletic trainer, teacher, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with event activities, and hereby release, discharge, and otherwise indemnify AUEF, US Club Soccer, AYSO, AAU, their sponsors, the USSF and its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the applicant/participant registering herein as a result of that applicant/participant participation in Programs selected above. I acknowledge that I understand that all registration fees paid are non-refundable.

Email
This field is for validation purposes and should be left unchanged.