Online Bill Payment

Cardholder Information

Date*

Name of client*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Phone number*

Enter your primary phone number. If we have trouble we will call this number.

Billing address options*

Use home address
Enter a different billing address

Billing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email receipt requested?*

Yes
No

Email address*

Would you like to set up automatic debit?

Yes
No

For recurring payment please complete the additional information below.

I authorize Child & Family Agency to charge my credit card for payment of my childcare or BP Learned for the amount, date, and frequency listed below.

Recurring payment amount*

This amount is not charged today. To make a payment today, please enter amount in "Today's Payment Amount" (further below).

Day/Date of payment*

Frequency*

(Weekly, Bi-weekly, Monthly)

Payment Information

Payment for:*

Childcare Groton ECDC
Childcare New London NLDN
BP Learned
Other clinical services (mental health/psychiatry/physical)

Today's payment amount:*

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Comments

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Make a credit card payment

Online Bill Payment

Cardholder Information

For recurring payment please complete the additional information below.

Payment Information