The Well - Morning/Afternoon Club

To use your credit card, please fill out:

Morning Club/Afternoon Club

Select number of sessions

Number: 1 Morning session for $15.00	Subtotal
Number: 10 Morning sessions for $135.00	Subtotal
Number: 1 Afternoon session for $10.00	Subtotal
Number: 10 Afternoon sessions for $90.00	Subtotal
Number: Unlimited Morning & Afternoon visits per month for $140.00	Subtotal
Please list participating children with Name, Age and Birthdate:
	First Name
	Last Name
	Address
	City
	State
	Zip
	Phone
	Cell Phone
	email

Total Amount*
*Must be filled in for to process credit card.