Credit Card Authorization Form

    CREDIT CARD AUTHORIZATION FORM

    Revised November 2017

    * Indicates a required field

    This is to authorize Center for Developing Kids as of:

    to make automatic credit card charges against my credit card account, until revoked, upon issuance of monthly invoices or for insurance co/pays for therapy services for my child:


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

    Please sign below.