Make a Payment for Doc Wayne Clinical Services or the Champions Network® Training NameThis field is for validation purposes and should be left unchanged.Client Name:(Required)Individual Client Name or Organization Primary Contact NameOrganization Name:Required for Champions Network® ClientsPhone(Required)Email(Required) Invoice Number:(Required)Payment Amount: Total Payment for:(Required)Doc Wayne Clinical ServicesChampions Network® Training or WorkshopWelcome Breaking the Silence (Ohio) participants! Any questions or challenges? Please reach out to us at: championsnetwork@docwayne.orgFor Doc Wayne Clinical Services:Clinical Services Provided: Individual Therapy For Champions Network®:Services Provided: Trauma Informed Care (TIC) TIC: Supporting Athletes of Color TIC: Supporting LGBTQIA+ Athletes Creating Champions: Level 1 Creating Champions: Level 2 Creating Champions: Level 3 Creating Champions Level 1 Support Workshop Learning Community Subscription Other Please select all training or workshops.If other, please respond:Payment InformationCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Billing Address for Credit Card(Required) Street Address City State / Province / Region ZIP / Postal Code Note:
