Tunica Academy - Misc Fees
Student's First and Last Name
Student's Date of Birth MM/DD/YYYY
Student's Grade
Registration Fee 2019-2020:   $200.00   Item Subtotal:  
Parent/Guardian Contact Information
Father's Full Name
Father's Email Address
Father's Cell Phone
Father's Home Address (City, State, Zip)
Father's Employer Name and Phone Number
Mother's Full Name
Mother's Email Address
Mother's Cell Phone
Mother's Home Address (City, State, Zip)
Mother's Employer Name and Phone Number
Emergency Contact Full Name
Emergency Contact Phone Number

Payer's Information
First Name: Last Name:
City: State/Province: ZIP/Postal Code:
Phone: Email:
Payment Information
Method of Payment:
Processing Fees: Credit cards: 2.9% plus $0.30
eChecks: $0.55
Update name from Payer's Information
Name of Individual
on Checking Account:
Name of Individual
on Savings Account:
Name of Business
on Checking Account:
Bank Routing Number:
Bank Account Number:
Credit Card Number:
Expiration Date: /
Card ID (CVV2/CID) Number: What is the Card ID?
Cardholder Information (exactly as it appears on your statement)
  Update from Payer's Information
Cardholder's Name:
Billing Street:
Billing ZIP/Postal Code:

Please be aware that payments will reflect on your statement as

Schools 800-764-0844 Clinton UT

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