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: TODAY'S DATE* 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: 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.