KC Client InformationPlease complete the form below . Child's Name * First Name Last Name Child's Age * Child's School * Child's Grade * Parent 1 Name * First Name Last Name Parent 1 Phone * (###) ### #### Parent 1 Email * Parent 2 Name First Name Last Name Parent 2 Phone (###) ### #### Parent 2 Email Address * Please provide the location for sessions if in person. Otherwise please provide your child's primary home address Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Payment Method * You will be a sent an invoice at the end of each month for the month's sessions. Please select how you would like to make payment. e-transfer credit card (3.5% service fee applies) Credit Card Number * Regardless of your preferred payment method, Kids Collaborative requires your credit card number to keep on file. Any invoice more than 7 days past due will be charged to the card and a 3.5% service fee will apply. Name on Card * Credit Card Expiration Date * Please provide month/year Credit Card CVV * Home Postal Code * Thank you! We look forward to working with your family.
