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.