Class Authorization Form.

SENSORY BOUNCE is a weekly class offering 3 payment options.

Option 1: Direct-Payment from FI.

A MONTHLY FEE OF $350.00 in which participants are committed to authorizing payment for all scheduled classes that month regardless of attendance. For clients who have been approved to use their self-direction budget toward Sensory Bounce, by choosing Option 1, when possible, Sensory Bounce will direct bill the client’s FI for all scheduled classes at the end of the month. A list of scheduled classes will be sent to the client at the beginning of the month for the participant to sign. Form must be returned by the 2nd of the month in order for the child to attend classes that month.

Option 2: Reimbursement of Payment from FI.

A MONTHLY FEE OF $350.00 in which participants are committed to authorizing payment for all scheduled classes that month regardless of attendance. For clients who have been approved to use their self-direction budget toward Sensory Bounce, but only have the reimbursement option available through their FI, the participant will be charged the $350.00 monthly fee at the beginning of each month. At the end of each month, client will be sent a FI-ready receipt with proof of payment.

Option 3: Self-Pay per Class.

A WEEKLY FEE OF $100.00 per class where participants can opt to pay on a weekly basis. For clients choosing Option 3, participants are required to to keep a credit card on file and self-pay per class. Clients will be given a receipt to submit to their FI for reimbursement.

A fee of $200.00 (for 2 classes) will be charged to the credit card on file prior beginning of the month. Additional charges will be made weekly if the child attends.

NEW PARTICIPANTS ARE REQUIRED TO COMMIT TO THE PROGRAM FOR TWO MONTHS.

AFTER 2 MONTHS, PARTICIPANTS MAY OPT OUT OF SENSORY BOUNCE AT ANY TIME PROVIDING WE RECEIVE A REQUEST BY EMAIL ON OR BEFORE THE 25TH OF THE MONTH. EMAILS CAN BE SENT TO INFO@SENSORYBOUNCE.COM.

SENSORY BOUNCE GUARANTEES THAT THERE WILL BE A MINIMUM OF 3, AND MAXIMUM OF 5 SESSIONS PER MONTH). THERE ARE NO REFUNDS OR CREDITS FOR MISSED OR CANCELLED SESSIONS.

BY SIGNING BELOW YOU ARE ACKNOWLEDGING THAT YOU AGREE TO HAVE THE CARD YOU SUBMITTED ON YOUR REGISTRATION FORM, AUTOMATICALLY CHARGED BY SENSORY BOUNCE, LLC AT THE RATE OF $350.00 MONTHLY ( for those opting for self-pay) or $200.00 (the cost of 2 classes) UNLESS OTHERWISE AGREED UPON AND THAT YOU AGREE TO THE TERMS OF THE PROGRAM STATED ABOVE

PLEASE ACCEPT AND SUBMIT THIS POLICY AND PAYMENT AUTHORIZATION FOR YOUR REGISTRATION TO BE COMPLETE.