Lewes Counseling - Pay Online

Payment for...*

Relaxation, Mindfulness, Yoga = PWYC

Pay What You Can*

Participant's Name*

First Name

Last Name

First Name

Last Name

Desired Relaxation, Mindfulness, Yoga Class Date*

Email*

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Emergency Contact*

Emergency Contact Phone *

Payment Amount (including $2.95 online convenience fee) $

Payment Amount (Pay What You Can) $

Comments

Total Payment Due Now $

Credit Card*

Cardholder's Name*

First Name

Last Name

I agree to the terms and conditions, below

Waiver & Release of Liability*

I agree to the waiver & release of liability below

Click here to view the terms and conditions

Click here to view the waiver & release of liability