Childcare Solutions

CHILDCARE SOLUTIONS

Information Update & Billing Authorization Form

This is a SECURE form.
It is SSL encrypted to protect your personal information.
* = required information

Your Name...

*Client Information first name last name
*Email Address:

Your Credit Card Information...

Full Name as it appears on the credit card full name as it appears on your credit card
Full Name as it appears on your credit card
Billing Address where you receive your credit card statement
*billing Street Address

*billing City

*blling state

*billing zip code

Please enter the address at which you receive your credit card statement.
*Card Number: - - -
Please enter only numbers
*Expiration Date:
Please enter Month and Year
*CVV Code: please enter security code from back of card
*Card Type: please select a card type

*finish by agreeing to our Terms of Service...
When you sign below and click on the 'submit' button we will have everything we need to continue working with your family. This is a 100% Secure Form utilizing 128bit SSL data encryption for your security and protection.

Agreement and Authorization

I have read the Childcare Solutions Client Contract and agree to all of the terms contained therein.
I agree to pay for all services I order from Childcare Solutions per the price schedule contained in the current Client Contract.
I authorize Childcare Solutions to charge all fees due to the credit card I place on file for that purpose.

*Please enter your full name to sign this agreement:

*Date: (dd/mo/year)