EOLD Hawaii - Sept 2024 -- Payment Plan Agreement

End-of-Life Doula Training - Payment Plan Agreement

Sept 27 - 29, 2024
Full Name*
Billing Address*
Cell Phone Number*
Billing Phone Number*
Please enter the phone associated with the payment method you've selected below
Email Address*
MonthDayYear
Today's Date
Plan Details:
- The payment plan is based on the full cost of the training.
- A registration fee of 50% of the total tuition must be paid before your registration will be accepted.
- Your final payment shall be paid no later than August 15, 2024.
- There is a one-time administration fee of $100 for all payment plans, which will be added to your initial registration fee.
- Payments may be made by credit/debit card or E-check. All payments will use the same method and will be processed automatically on the schedule you choose.
- All payments will be processed through Dr. Charlotte Charfen's business, Fusion Medicine & Wellness LLC.
Choose the plan that works best for you:*

One additional payment, equaling the balance of your total tuitionTwo additional payments, each to be half of remaining balance
Date you would like first additional payment processed: *

MonthDayYear
If choosing two additional payments, date you would like the second additional payment processed:

MonthDayYear
Payment Schedule - EarlyBird Discount

Total Tuition: $1356.02
- Initial Registration Fee: $778.02
  (50% of tuition $678.02+ $100 payment plan administration fee)
- One additional payment: $678.00
- Two additional payments: $339.00 each
Payment Schedule

Total Tuition: $1,565.44
- Initial Registration Fee: $883.44
  (50% of tuition $783.44 + $100 payment plan administration fee)
- One additional payment: $782.00
- Two additional payments: $391.00 each
Payment Type:
Choose your preferred method of payment*

Credit/Debit CardeCheck

Terms and Conditions
Refund Policy

Included in your tuition is a 25% non-refundable, non-transferable cancellation fee.
- Cancellations received before August 16, 2024 will receive a full refund of tuition, less the 25% cancellation fee.
- Cancellations received before August 30, 2024 will receive a refund of 50% of tuition, less the 25% cancellation fee.
- There will be no refund for cancellations received on/after September 1, 2024.
Please initial below to acknowledge your agreement with the refund policy.*
eCheck Payment Authorization

With my signature below, I authorize Fusion Medicine & Wellness LLC to process regularly-scheduled payments to my checking/savings account in accordance with my selections above. No prior notification will be provided unless the date or amount changes. I agree that my payment information will be stored by the payment gateway facility. I understand that this authorization will remain in effect until I withdraw it by submitting a request in writing to Inspired Endings LLC.

I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank, so long as the transactions correspond to the terms indicated in this authorization form.
Credit Card Payment Authorization

With my signature below, I authorize Fusion Medicine & Wellness LLC to process regularly-scheduled charges to my credit card in accordance with my selections above. No prior notification will be provided unless the date or amount changes. I agree that my payment information will be stored by the payment gateway facility. I understand that this authorization will remain in effect until I withdraw it by submitting a request in writing to Inspired Endings LLC.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions, so long as the transactions correspond to the terms indicated in this authorization form.
Signature*

Clear
Note: Please click print before submitting if you would like a copy of your agreement for your records.
Should be Empty:

End-of-Life Doula Training - Payment Plan Agreement

Plan Details:

Payment Schedule - EarlyBird Discount

Payment Schedule

Payment Type: