Credit Card Change/Refund Request

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This form is to be submitted to either request a refund or to have your Credit Card information changed. Once a refund is requested we will review the account. We will respond in writing the decision.

Email *

Child(ren) Name(Please add all the children's names One form per family) This is to make sure it is applied to each child properly *

Refund For *

After care

Half Care

School Closing Care

Credit Card Change Request

Please Provide Information on your new card.

New Card Number and CVC Code on the back. Example: 444-4444-4444 CVC 000 *

Expiration Date *

Name on Card and Billing Address *

Last 4 digits of card you are cancelling. *

Authorization

I authorize The Discovery Lounge, Inc to charge my credit card for agreed upon Reoccurring weekly fees, Child Care Services, Fees and Balances. I agree that my card information will be saved for future transaction on my account. I agree that all the information is true and accurate and I am the authorized owner/user of this card and assume all financial responsibilities.

Do you Authorize the use of this card and validate the accuracy of the information *

Yes

Name of Person Filling out Form *

Submit

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