Client Payment Form

Auto-Pay Information
Family Name/Corporate ID*/Business Name:*

*If you are a corporate care benefit family please provide your Student/Employee ID number or other Corporate ID.
Email*

Please enter the email address we have on file for your family's main contact.
Name (as it appears on card/account)*
First Last
I am...*
- An Existing Client
- A New or Returning Client
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please select a payment option:
- ACH/Bank Account** (Recommended, see below)
- Credit Card (Subject to a 3% processing fee)
**ACH transfers are inherently more secure. When you make an ACH payment, it processes through an encrypted, secure system. The payment is then processed in a safe, secure environment, giving your credentials increased protection.
Account Number*
Routing Number*
Account Type*
- Checking
- Savings
Card Type*
Expiration Date*
Credit Card Number*
Signature*
By signing above you ("Client") are authorizing Trusting Connections ("TC") to automatically charge the account designated above to pay any outstanding invoices for service or membership fees accrued.
Date*
Month
Day
Year
CAPTCHA

Auto-Pay Information