Authorization Form

SENSORY BOUNCE® is a weekly class offering 3 payment options.

I authorize my child to be photographed or video taped solely to promote the benefit of Sensory Bounce Therapy *
Option 1: Direct-Payment from FI.

A WEEKLY FEE OF $100.00 in which participants are committed to authorizing payment for all scheduled classes that month regardless of attendance. For clients who have been approved to use their self-direction budget toward Sensory Bounce®, by choosing Option 1, when possible, Sensory Bounce® will directly bill the client's FI for all scheduled classes at the end of the month. A list of scheduled classes will be sent to the client at the beginning of the month for the participant to sign. Form must be returned by the 2nd of the month in order for the child to attend classes that month.

Option 2: Reimbursement of Payment from FI.

A WEEKLY FEE OF $100.00 in which participants are committed to authorizing payment for all scheduled classes that month regardless of attendance. For clients who have been approved to use their self-direction budget toward Sensory Bounce®, but only have the reimbursement option available through their FI, the participant will be charged the $100.00 weekly fee at the beginning of each month. At the end of each month, the client will be sent a FI-ready receipt with proof of payment.

Option 3: Self-Pay per Class.

A WEEKLY FEE OF $100.00 per class where participants can opt to pay on a weekly basis. For clients choosing Option 3, participants are required to keep a credit card on file and self-pay per class. Clients will be given a receipt to submit to their FI for reimbursement.

A fee of $200.00 (for 2 classes) will be charged to the credit card on file prior to the beginning of the month. Additional charges will be made weekly if the child attends.

NEW PARTICIPANTS ARE REQUIRED TO COMMIT TO THE PROGRAM FOR ONE MONTH.

AFTER 1 MONTH, PARTICIPANTS MAY OPT OUT OF SENSORY BOUNCE® AT ANY TIME PROVIDING WE RECEIVE A REQUEST BY EMAIL ON OR BEFORE THE 25TH OF THE MONTH. EMAILS CAN BE SENT TO [email protected] and
[email protected]

THERE ARE NO REFUNDS OR CREDITS FOR MISSED OR CANCELED SESSIONS. BY SIGNING BELOW YOU ARE ACKNOWLEDGING THAT YOU AGREE TO HAVE THE CARD YOU SUBMITTED ON YOUR REGISTRATION FORM, AUTOMATICALLY CHARGED BY SENSORY BOUNCE®, LLC AT THE RATE OF $100.00 WEEKLY ( for those opting for self-pay) or $200.00 (the cost of 2 classes) UNLESS OTHERWISE AGREED UPON AND YOU AGREE TO THE TERMS OF THE PROGRAM STATED ABOVE.

PLEASE ACCEPT AND SUBMIT THIS POLICY AND PAYMENT AUTHORIZATION FOR YOUR REGISTRATION TO BE COMPLETE.

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