Premium Level Summer Enrollment Form
Please complete all required information noted with an *.
Are you...
*
Enrolling
Renewing
Updating
Pausing
Cancelling
Full Name:
*
Business Name:
Shipping Address:
*
City:
*
State:
*
Zip Code:
*
Email Address
*
Telephone Number:
*
Preferred Payment Method:
*
Credit Card (Automatic)
Credit Card (Invoice)
PayPal (Invoice Only)
PayPal Email (If Applicable):
First Set of Digits of Credit Card Number (If Applicable):
Second Set of Digits of Credit Card Number:
Third Set of Digits of Credit Card Number:
Last Set of Digits of Credit Card Number (If Applicable):
Credit Card Expiration xx/xx:
Credit Card CVV:
Billing Address (If different from shipping address):
Desired Billing/Invoice Date:
*
1st Available
15th of the Month
20th of the Month
Curriculum Style:
*
City Bears
City Bears w/ Extra Activities
Country Bears
Country Bears w/ Extra Activities
Basic Kits:
*
Precut Materials:
Ready to Cut Materials:
Toddler Copies:
Toddler Combo Copies:
Preschool Copies:
Preschool Combo Copies:
Toddler Supplies:
Preschool Supplies:
Parent Newsletters:
City Bears Cubbie Tags:
Country Bears Cubbie Tags:
Menu:
*
None
Lunch
Snack
Alternating
Both
School Year Curriculum (September-May):
*
Yes
No
Maybe
This space is for any additional information or questions you may have.
Submit Form