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*
Format: (000) 000-0000.
Billing Phone Number*
Please enter the phone associated with the payment method you've selected belowFormat: (000) 000-0000.
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.
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:
Credit/Debit CardeCheck
- Credit Card Number*
- Expiration Date*
  
  MonthDayYear
- CVV*
- Bank Name*
- Consumer CheckingConsumer SavingsBusiness CheckingBusiness Savings
- Bank Routing Number*
- Bank Account Number*
- 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*
- 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: