Course Payment

"*" indicates required fields

Registrant Information

If paying for multiple courses/attendees or services, please include details in the Notes section below.

Service / Course Title*

Please identify what you are paying for. For courses, enter the course title. For invoices, health contracts, or other payments, enter relevant details or identify the service.

Course Date*

If a multi-session course, please list the date of the first meeting.

Location*

Attendee Name(s) (First and Last)*

Provide the first and last name of all attendees.

Business / Center Name

Payment Information

Credit Card Information

Card Details

Cardholder Name

Cardholder Email*

Cardholder Phone*

Billing Address*

Street Address City / Town State ZIP Code

Child Care Council Membership # (if applicable)

Total Cost*

Notes

Comments

This field is for validation purposes and should be left unchanged.

Course Payment

Registrant Information

Payment Information

New Service Aims to Reduce Child Care Suspensions, Expulsions of Children with Special Needs