Fu Zu Ba Student Massage Clinic Registration Form

FU ZU BA School Student Massage Clinic Customer Registration Form 富足吧学生按摩客户注册表
阅读并打勾 Read and check*

Student massage clinic is performed by training students and supervised by instructors. Students shall not accept any compensation for this service. 学生按摩治疗是由在校学生在老师监督下提供的按摩服务. 学生不能为该服务收取任何报酬.
阅读并打勾 Read and Check*

Student massage trainees will be appointed to you by instructors. 学生按摩师由老师指定.
阅读并打勾 Read and Check*

All student massage clinic will be conducted at the classroom site. 所有学生按摩将在按摩教室进行.
阅读并打勾 Read and Check*

I understand that I may not be treated if I have contra-indications. You may consult with the supervising instructor if not sure. 我知道如果有禁忌症, 将不会被按摩. 如有疑问, 可以询问监督的老师.
Internal Use Only 内部使用，不需填写
Your payment is processed by authorized.net directly. We do not store your payment information.
Registration must be completed online by the customer along with an appropriate payment to be valid. 注册流程要求申请人在网上登记，同时完成信用卡或银行卡付费信息。
Payment Status
Appointment 预约时间*

Choose and pay 选择并付费*

Chair Massage 30-min椅背按摩 30分钟

$20.00

Swedish Massage one-hour瑞典油压一小时

$30.00

Total

$0.00

Credit Card or Debit Card 信用卡或者银行卡信息

First Name 名

Last Name 姓

Credit Card Number 信用卡号码

Security Code 信用卡安全号 3-4位

Expiration Month 有效期月份

Expiration Year 有效期年份

Billing Address (must match the bank record) 信用卡或银行卡账单地址 (必须跟银行记录相符)

Street Address 地址

Street Address Line 2 地址（第二行）

City 城市

State / Province 州

Postal / Zip Code 邮编 5位数

Country 国家（Select the 1st one: USA; 选择第一个：美国）

FU ZU BA School Student Massage Clinic Customer Registration Form 富足吧学生按摩客户注册表