teacher_checkout - Child Care Forward

First Name*

Billing Address*

State*

Country/Region*

Email*

Center Name*

Center Phone*

Center City*

Total Cost $

I understand that the fee paid for this Medical Evaluation is non-refundable. I can reschedule if I inform Child Care Forward, in writing by email, at least 24 hours prior to my appointment. If I do not inform Child Care Forward at least 24 hours prior to my appointment and I am unable to attend my Medical Evaluation TEAMS meeting on time, I understand I will not receive a refund.

I agree

I understand I need to show a government-issued picture ID at the beginning of our online session.

I agree

Last Name*

Zip Code*

Phone*

Billing Create Password*

OPTIONAL- Additional Information

Total Cost $