Preferred Customer Summer Enrollment Form
Please complete all required information noted with an *.
Are you...
*
Enrolling
Renewing
Updating
Cancelling
Membership Level
*
Preferred
Plus
Premium
Full Name:
*
Business Name:
Shipping Address:
*
Address Line 2:
City:
*
State:
*
Zip Code:
*
Email Address:
*
Telephone Number:
*
What is Your Preferred Payment Method?
*
Credit Card (Invoice)
Credit Card (Automatic)
PayPal (Invoice Only)
PayPal Email (If Applicable):
Credit Card Number:
Credit Card Expiration xx/xx:
Credit CVV:
Please Select Your Desired Billing/Invoice Date:
*
1st Available
10th of the Month
15th of the Month
20th of the Month
Select Item 5
Curriculum Style:
*
Country Bears
Country Bears w/ Additional Activities
City Bears
City Bears w/ Additional Activities
Basic Kits:
*
Precut Materials:
Toddler Supplies:
Pre-K Supplies:
Toddler Copies: or
Toddler Combo Copies:
Pre-K Copies: or
Pre-K Combo Copies:
Parent Newsletters:
Additional Newsletters:
City Bears Cubbie Tags:
Addtional City Bears Cubbie Tags:
Country Bears Cubbie Tags:
Menu:
None
Lunch
Snack
Alternating
Both (additional $.10)
School Year Curriculum (September-May):
Yes
No
Maybe
This space is for any additional information or questions you may have:
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