SIPlive: Independence/Summit Academy/Jr. High/Elem

Independence Jr. High Campus Registration

Student's Full Name	Last Name	,	First Name
Student's Full Name

Jr. High Registration Fees:

$100.00

Quantity:

Item Subtotal:

$0.00

Yearbook:

$30.00

Quantity:

Item Subtotal:

$0.00

Total:

$0.00

Parent/Guardian Information

First Name:		Last Name:
Phone:		Email:

Please be aware that payments will reflect on your statement as

Schools 800-764-0844 Clinton UT

Payment Information

Method of Payment:

Processing Fees:

Credit cards: 3% plus $0.50 ($1.50 min)
(+1.5% processing fee for foreign cards)
eChecks: $0.49

	Update name from Parent/Guardian 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:

Cardholder Information (exactly as it appears on your statement)
	Update from Parent/Guardian Information
Cardholder's Name:

Billing ZIP/Postal Code:


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