1. CLIENT PAYMENT INFORMATION

Please provide your payment details. These will be securely processed for the purpose of coaching services.

Full Name (as it appears on the payment account):
(Input Field)

Billing Address:
(Input Field)
(Street Address, City, State, Zip Code)

Email Address (for payment receipts):
(Input Field)

Phone Number (for payment-related inquiries):
(Input Field)

Payment Method:
(Dropdown options)

  • Credit Card

  • Debit Card

  • Bank Transfer

  • PayPal

  • Other: (Input Field)

If paying by Credit Card or Debit Card, please provide the following:

Card Number:
(Input Field - Credit Card Number)

Expiration Date:
(Date Picker)

Card Verification Value (CVV):
(Input Field)

Cardholder's Name (on the card):
(Input Field)

If paying by Bank Transfer, please provide the following:

Bank Name:
(Input Field)

Account Holder's Name:
(Input Field)

Account Number:
(Input Field)

Routing Number:
(Input Field)

If paying by PayPal, please provide your PayPal Email:
(Input Field)

2. AGREEMENT ON PAYMENT SCHEDULE

Please select your payment plan. This will determine how payments are scheduled and processed.

Payment Type:
(Radio buttons)

  • One-Time Payment

  • Recurring Payment (e.g., Monthly Subscription)

For Recurring Payments, please select the payment frequency:
(Radio buttons)

  • Weekly

  • Monthly

  • Quarterly

  • Annually

Payment Amount:
(Input Field)
(e.g., $199 for one-time payment or $29/month for subscription)

Next Payment Due Date (if applicable):
(Date Picker)

3. CANCELLATION AND REFUND POLICY

Please review the cancellation and refund policy. By submitting this form, you agree to the terms outlined below.

Cancellation Policy:
(Text Area)
(Please provide the terms of the cancellation policy, such as the notice period required for cancellation, any fees associated with early termination, etc.)

Refund Policy:
(Text Area)
(Describe under what circumstances a refund will be issued and any specific terms.)

Do you agree to the cancellation and refund policies?
(Checkbox)

  • Yes, I agree to the cancellation and refund policies.

  • No, I do not agree to the cancellation and refund policies. (This may prevent processing the payment)

4. AUTHORIZATION TO CHARGE ACCOUNT

By signing this form, you authorize the coach to charge your payment account according to the agreed payment schedule for coaching services.

I hereby authorize the coach to charge my selected payment method (Credit Card, Debit Card, Bank Account, PayPal) for the agreed amount based on the selected payment schedule.
(Checkbox)

  • Yes, I authorize the payment to be processed.

I agree to the payment terms as outlined above:
(Checkbox)

  • Yes, I agree to the terms.

5. E-SIGNATURE & ACKNOWLEDGEMENT

By signing below, you confirm that the information provided is accurate and that you agree to the payment schedule, cancellation policy, refund policy, and authorization to charge your account.

Client Signature:
(Electronic Signature Field)

Date:
(Date Picker)