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Independence Jr. High Campus
Student's Full Name
Last Name
,
First Name
Student ID #?
Curricular Fees
Spanish 1:
$10.00
Quantity:
Item Subtotal:
$0.00
Spanish 2:
$10.00
Quantity:
Item Subtotal:
$0.00
Band:
$55.00
Quantity:
Item Subtotal:
$0.00
German DLI Culture:
$10.00
Quantity:
Item Subtotal:
$0.00
Sewing Class:
$20.00
Quantity:
Item Subtotal:
$0.00
Foods Class:
$20.00
Quantity:
Item Subtotal:
$0.00
Art Class:
$20.00
Quantity:
Item Subtotal:
$0.00
Sculpting Class:
$20.00
Quantity:
Item Subtotal:
$0.00
Lego Robotics Class:
$10.00
Quantity:
Item Subtotal:
$0.00
Extra-Curricular Fees
Basketball Participation:
$170.00
Select:
Item Subtotal:
$0.00
Cross Country Participation:
$90.00
Select:
Item Subtotal:
$0.00
Soccer Participation:
$140.00
Select:
Item Subtotal:
$0.00
Volleyball Participation:
$130.00
Select:
Item Subtotal:
$0.00
After School Band (non-waivable):
$100.00
Select:
Item Subtotal:
$0.00
Student Council:
$100.00
Select:
Item Subtotal:
$0.00
Non-Waivable Fees
Jr High Yearbook:
$35.00
Quantity:
Item Subtotal:
$0.00
Yearbook Sweatshirt:
$35.00
Quantity:
Item Subtotal:
$0.00
Athletic Sweatshirts:
$26.00
Quantity:
Item Subtotal:
$0.00
Sports Uniform Not Returned:
$
Item Subtotal:
$0.00
Book Not Returned Fee:
$
Item Subtotal:
$0.00
Balance Rollover:
$
Item Subtotal:
$0.00
Miscellaneous Fee:
$
Item Subtotal:
$0.00
Please describe other fees you are paying for:
Technology Fees: Non-Waivable
Chromebook Charger Replacement:
$25.00
Quantity:
Item Subtotal:
$0.00
Chromebook Screen Replacement:
$75.00
Quantity:
Item Subtotal:
$0.00
Chromebook Full Replacement:
$250.00
Quantity:
Item Subtotal:
$0.00
Case:
$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
CBT*SUMMIT ACADEMY
and the service fee as
CBT*SVC FEE SUMMIT A
.
Payment Information:
Processing Fee Rates:
Cards:
3% plus $0.50 ($1.50 min)
(1.5% additional service fee for foreign cards)
eCheck:
$0.49
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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