Credit Card Authorization Form – Howell Dance Fields that have an * are required. "*" indicates required fields Student's Name* Card Holders Name* Email* Phone*Credit Holders Billing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Card Type* Visa MasterCard Account #* CVV/CVC Code* Exp. Date* Payment Terms: Digital Signature* I agree to the Payment Terms.Electronic Signature Needed: If Howell Dance does not receive my payment by the 7th of the month, my tuition payment and a $10.00 late fee will automatically be charged to my above listed credit card. I understand that my monthly tuition is payable by check or cash, due by the 1st of every month and that credit cards that are denied will result in an additional $25.00 fee. I hereby authorize Howell Dance and/or e-online data to bill my credit card for any monthly fees not received into the studio by 7:00pm on the 7th of the month which represents my Late Tuition Payment in accordance to my tuition contract. I, also authorize Howell Dance and/or e-online data to bill my credit card for any outstanding costume not paid into the studio by the due dates with a $10.00 late fee. This is my Electronic Signature. Participation Conditions: Digital Signature* I agree to the Participation Conditions.Electronic Signature Needed: As a condition of participating as a student at Howell Dance (“HD”), I, acknowledge that I fully understand the risks inherent to participation at HD, and I expressly agree, on behalf of myself, my heirs, executors, administrators, successors, and/or assigns, to release and hold harmless Howell Dance, April Bamonte and their respective subsidiaries, affiliates, agents, officers, directors, volunteers, managers, other vendors, and employees (each of the foregoing, collectively, the “Releases”) from and against, any and all damages, losses, expenses (including attorneys’ fees and costs) or injuries, and any and all other claims of any type whatsoever for any personal injury, death, disability, or damage to tangible or intangible property, or any other loss, damage, or injury of any nature whatsoever (collectively, “Claims”) relating to or sustained or caused at HD. Furthermore, I agree, on behalf of myself, my heirs, executors, administrators, successors and/or assigns, to indemnify and hold harmless the Releases from and against any and all Claims made by any third party arising out of my participation at HD. Such obligation shall not be construed to negate, abridge, or reduce other rights or obligations of indemnity which would otherwise exist as to any party or person described in this Release and Indemnity Agreement. I agree to keep confidential and not to disclose any non-public information, regarding HD or any of the Releases, disclosed to me during the course of my participation at HD. I give and grant to Howell Dance, April Bamonte and its officers, parent companies, employees, agents, representatives, affiliates, subsidiaries, consultants, independent contractors, successors, assigns, designees and licensees ("LIG"), the right to use and publish my name, nickname, voice, picture, portrait, likeness, characteristics, live or recorded performance, photograph, signature or facsimile thereof, and biographical materials (the “Identity”) as embodied in materials associated with HD marketing, advertising, sales or promotional efforts (the “Materials”) in all forms of media now known or hereafter created, including without limitation, video, television, print, billboards, point-of-purchase materials, corporate communications, internal and external marketing pieces, and Internet in any and all territories throughout the world. In the event that any clause, term, or provision of this agreement shall be deemed or adjudicated void or invalid, it shall in no manner affect the validity or enforceability of the remaining clauses, terms, and provisions herein which shall remain in full force and effect. I hereby acknowledge that I have read the Release and Indemnity Agreement and am satisfied that it is fair and equitable. I shall not revoke this consent and approval. I have read and understand the Howell Dance liability release and indemnity agreement: This is my Electronic Signature.PhoneThis field is for validation purposes and should be left unchanged.