Intake Form

Please fill out the following information including credit card information for billing purposes.  Submission of this form gives consent for the following:

By providing the electronic signature below, I hereby authorize the CENTER FOR EDUCATIONAL SERVICES (CES) to charge my credit card the balance on my account at the end of the calendar month if alternative payment (via check) is not provided ahead of time.

I will receive a monthly statement via email that will be a receipt of what was paid.  In addition, I am financially responsible for payment of fees as well as missed sessions unless cancelled 24 hours in advance (unless there is an emergency and the tutor has been notified in advance).

Being the cardholder, I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card for the services provided as stated above. I understand that my credit card information is being kept confidential and secure via Stripe.

I also consent to the following: I understand that the tutoring offered by CES is of a voluntary nature.  I further understand that no information obtained about me or my child by CES will be shared with anyone without my permission.

Credit Card Details
Student
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