Client / Member Information
Full Name: {name}
Date of Birth: {dob}
Address: {address}
Phone Number: {phone}
Emergency Contact Name: {contact_name}
Relationship: {contact_relation}
Emergency Contact Phone: {contact_phone}
Payment Terms
1. Invoice Payment Terms
All invoice payments are due within 30 days from the date the invoice is issued.
A late payment fee may be applied to invoices that are 60 days overdue.
2. Accepted Payment Methods
Payments may be made via direct deposit.
If paying by check, checks must be made payable to TheCube Basketball, Inc. and mailed to:
70 POST DR, ROSLYN NY 11576
3. Timely Payments
Clients are responsible for encouraging their Fiscal Intermediaries (FIs) to submit payments in a timely manner.
4. Client Responsibility
Clients understand and agree that they are ultimately responsible for any unpaid balances not honored by the Fiscal Intermediary, even if services have already been rendered.
If payment remains unpaid after the allotted time, the client will be held financially responsible for the outstanding balance.
5. Invoice Processing Notification
Fiscal Intermediaries must notify TheCube Basketball, Inc. of invoice status and confirm when invoices have been processed.
Notification must be sent via email within 15 days of invoice receipt.
6. AutoPay Service
Clients enrolled in AutoPay must provide 30 days written notice to discontinue the service.
Failure to do so will result in continued deductions with no refunds.
Acknowledgment
I acknowledge that I have read, understand, and agree to the payment terms outlined above.
Client / Member Initials:
Date {sign_date}
TheCube Basketball
