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

Mandatory Fees

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

Partial payment of required fees is due now if you haven't checked the above "Fee Waiver" box.

The balance will be due in August

Partial Payment of Mandatory Fees for Grades 7,8:

$170.00

Select:

Item Subtotal:

$0.00

Partial Payment of Mandatory Fees for Grades 9-12:

$195.00

Select:

Item Subtotal:

$0.00

Mandatory Fees include the following: Activity Fee, instructional & laboratory materials, texts, technology, software, equipment licenses, and transportation fee.

Optional

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% surcharge 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:

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