Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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I wish to donate all or part of my refund to Bauman Wellness *

Full amount of tuition

Partial amount

Authorization *

By submitting this form I authorize Bauman Wellness to process the above donation amount using the payment method indicated above. I understand that my donation is tax-deductible to the extent allowed by law.

Yes, I authorize my tuition (total or partial as indicated above) to be used as a donation to Bauman Wellness