Bank Draft Registration Form

Name ______________________________________

Address ___________________________________________________

City _________________________State___________Zip_____________

Phone _(_____)________________________

I authorize Wisconsin Christian Youth Camp and the financial institution named below to charge my account each month, in the amount shown below. This authority will remain in effect until I give written notice to cancel it. I understand that all changes of status to this agreement may take three to six weeks to be processed.

Amount per month ___________

Monthly withdrawal date (check only one)   _______ first      ________ fifteenth

Thank you for your commitment to WCYC's ministry to youth

Financial Institution's name _____________________________________________

Acount number _____________________________________

Financial Institution's address _____________________________________________

Please enclose a voided check or savings deposit slip

Signature __________________________________________ Date _______________

Please mail this form to:

Tim Shilts

S64 W25280 Meyers Drive

Waukesha, WI 53189