Monthly Membership Recurring Payment Authorization Form

You authorize Sarah Eiler/Reflexology By Sarah to make regularly scheduled charges to your Credit or Debit card. Your monthly rate will be deducted on the 1st of EACH MONTH for a period of one year (12 consecutive months).

Any unused sessions roll over to subsequent month(s) for up to three months. After three months, any unused, prepaid sessions expire. 

Membership Benefits are non-transferable. There are no additional fees or contract. 

Membership cancellation must be made in writing 7 days prior to cancellation effective date. 

If you cancel your Membership, you have up to 3 months from the date of cancellation to use any prepaid sessions.

Member Name  __________________________________

My One Year Membership begins the month of ___________,_____ and ends  the month of ___________,_______.

Cardholder Name: _________________________________________ 

(Full name as it appears on card) 

Card Number: _________________________________________ 

Expiration Date: ____________     

Security Code: __________  

Card Billing Zip Code________

Membership Selected                           Amount

1 Hour Foot Reflexology                       $50

1.5 Hour Foot Reflexology + Reiki        $70

Signature ____________________________________ 

Date of Membership Activation____________________

Please return this form to activate your membership.  Here is a Google Doc version of the form as well: