CREDIT CARD AUTHORIZATION FORM

Revised November 2017

* Indicates a required field

This is to authorize Center for Developing Kids as of:

TODAY'S DATE*

to make automatic credit charges against my credit card account for services rendered. Monthly invoices with service and insurance funding details (when applicable) will be available promptly after payments are confirmed.

CHILD'S NAME*

NAME AS IT APPEARS ON CARD*

BILLING ADDRESS*

BILLING ZIP CODE*

PHONE*

EMAIL*

A receipt will be sent to the email address listed above.

CARD TYPE*
VISAMASTERCARD
CARD INFORMATION*
Please sign below.