IPRP Client Registration Information 

Client Name: Client first name Client last name

Client DOB: Client birthdate

Client Email: Client email

Client Phone: Client phone

Emergency Contact: Contact 1 name

Emergency Contact Phone #: Contact 1 phone 

Program Start Date: Client admit date

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Credit Card Authorization Form

By signing this form you give CFC Loud n Clear Foundation 501c3 permission to debit your account for the Intensive Peer Recovery Day Program in the amount of Dropdown. This is permission for a one time transaction to your account that is nonrefundable after the program start date designated below. By signing below, you are also agreeing to the following one time charge as stated above. 

Client Name: Client first nameClient last name

Payee Name: Text field

Date of Sign: Date

Date of Program Start: Date

Signature: Signature

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CREDIT CARD INFORMATION

Client Name: Text field

Account Type: Checkboxes

Cardholder Name: Text field

Card #: Text field

Expiration Date: Text field

CVV2 (3 Digit # on back of Visa/MC, 4 Digit on front of AMEX): Text field

Card Billing Address: Paragraph

Zip Code of Billing Address: Text field

Payee Phone Number: Text field

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Signature

Date

I authorize the above named business to charge the credit card / bank account indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above for the amount indicated above only. I certify that I am an authorized user of this credit card / bank account and that I will not dispute the payment with my credit card company / bank, so long as the transaction corresponds to the terms indicated in this form.