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Student Name *

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Last

Billing Information

Name on Card *

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Last

Email *

Billing Address *

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Line 2

City

State

Zip Code

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Credit Card Number (VISA/Mastercard) *

Expiration Date *

Comments (optional) *

* Billing takes place at the end of each week.
* We require 12 hours notice for reschedules and cancellations. (Unexpected illness and family emergencies excepted).
* If less than 12 hours notice is given a 50% fee will apply. If no notice is given the missed session will be billed at our full rate.

Please review our Billing Policies. *

-I agree to the Terms above.

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