Payment Arrangement Request Form

Please complete the form below

Use this form to request a Promise to Pay arrangement with The Diamond MVMT. Submitting this form does not stop AutoPay. Any scheduled AutoPay transactions will still be attempted.

⚠️ Dancers may not attend rehearsals or events unless a payment arrangement has been approved by our team.

Name

Account Holder | Parent or Gurdian

First Name

Last Name

Name

Student Name (If applicable)

First Name

Last Name

Region

Select the region your dancer participates in.

Division

Choose your dancer’s current division.

Email

Phone

(###)

###

####

Section 2: Payment Arrangement

Planned Payment Date

List the date you plan to make payment

MM

DD

YYYY

Planned Payment Amount

Enter the amount you plan to pay on the listed date.

$

Notes / Special Circumstances

Optional — include any details about your situation we should know.

Section 3: Acknowledgements

Acknowledgements

I understand this request does not stop AutoPay drafts.

I understand my dancer may not attend rehearsal unless this request is approved by The Diamond MVMT.

I agree to make payment according to the schedule I provide.

I understand that if my plan is not honored, my dancer may be removed from classes/events.

Typed Signature

Typing your full name serves as your signature for this agreement.

Payment Arrangement Request Form

Please complete the form below

✅ Thank You — Submission Received