Credit Card Authorization Form

CREDIT CARD AUTHORIZATION FORM

Revised November 2017

Child's Type Card

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 *

First

Last

Name (as it appears on card) *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

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

Card Type *

Card Number *

Exp. Date *

CVV *

Signature *

Clear Signature