City Academy - Misc Fees

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WELCOME TO CITY ACADEMY!

We look forward to seeing our returning and new students at City Academy this year.

Please call (801) 596-8489 if you have any questions

What school year are you registering your student for?

Student Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Student grade

Student Birth Date

Parent Name:

Parent Email:

Parent Phone:

Medical Consent Agreement

In the event of medical emergency, when parent or guardian cannot be reached or in life threatening situations, I authorize City Academy to obtain emergency medical care (i.e., physician, dentist, paramedic, or other authorized emergency medical agents) and to obtain and provide emergency transportation. I understand that I or my insurance, if applicable, will be billed for such emergency medical treatment.

I agree to the above Medical Consent Agreement

Check here if you expect to qualify for free meals/fee waiver. Mandatory fees are waived if you qualify for free status. Application form will be available in August.

Fee Waiver

~ Optional Donation ~

Parent School Organization (PSO) Donation:

$5.00

Select:

Item Subtotal:

$0.00

Donation to City Academy:

Item Subtotal:

$0.00

To help cover fees for families who cannot afford to pay them.

Total:

$0.00

Click on Continue and then Submit to complete this form. Thank You!

Payment Information:

Processing Fee Rates:
Cards:	3% plus $0.50 (1.5% additional service fee for foreign cards)
eCheck:	$0.50

Method of Payment:	Credit/Debit Card eCheck
Update Name from Above

Name on Account:
Routing Number:
Account Number:
Institution:

Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:

Payment method will be collected on external device

Change Payment Method

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