Change of billing method form

Please print this form out and fill in the required areas.

We request that you only switch billing methods twice during the calendar year.  This was initially implemented to help families who might be gone most of the time during the summer but who need to bring their children from time to time during those summer months.

Please have our director or assistant director sign the form and make you a copy for your files.

Unless the form is completed and signed, the billing method will not be changed.

Date of request _____________________

Date change is requested to be made _____________________

Children to be changed

1. ___________________________

2. ___________________________

3. ___________________________

4. ___________________________

Request change from ___ weekly ___ daily    TO    ___ weekly ___ daily

Family name the account is handled at Stepping Stones _________________________________________

Person requesting billing method change ____________________________________________________

Approved by : ____________________________________________________  Date ________________