Parent Name *

First Name

Last Name

Name on Credit Card/ Checking Acct.

Provide only if different than parent name (above)

First Name

Last Name

Student Name *

Name of student receiving tutoring services

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

By typing my name below, I ("the Client") authorize Scholastic Success to auto-debit my credit card or checking account for the full balance due 5 business days after Scholastic Success emails my monthly invoice. Maintaining sufficient funds and/or valid payment information on file is solely the responsibility of the Client. Failure to maintain sufficient funds and/or valid payment information on file could lead to the Client incurring additional fees/penalties for non-sufficient funds and/or late payment. Termination of auto-debit can occur by emailing accounts@scholastic-success.com and only after all outstanding services/invoice have been paid in full.

First Name

Last Name