Fillmore Middle School
             
Student NameLastname,Firstname-ID#
 
Lunch Fees
Reduced Lunch Monthly:   $8.00   Select:   Item Subtotal:  
$0.00
Reduced Lunch Yearly:   $72.00   Select:   Item Subtotal:  
$0.00
Regular Lunch Monthly:   $50.00   Select:   Item Subtotal:  
$0.00
Regular Lunch Yearly:   $450.00   Select:   Item Subtotal:  
$0.00
Other Lunch Amount:   $   Item Subtotal:  
$0.00
*All applications for free or reduced lunch must be submitted online at  http://MSD.heartlandapps.com for processing.
 
Grade 6
Writing Lab (Mandatory):   $6.00   Select:   Item Subtotal:  
$0.00
Year Book (Optional):   $25.00   Select:   Item Subtotal:  
$0.00
 
Grade 7
Writing Lab (Mandatory):   $6.00   Select:   Item Subtotal:  
$0.00
Locker Fee (Mandatory):   $1.00   Select:   Item Subtotal:  
$0.00
CTE (Mandatory for all 7th):   $6.00   Select:   Item Subtotal:  
$0.00
Beginning Fitness (Mandatory for all 7th):   $15.00   Select:   Item Subtotal:  
$0.00
Art (Mandatory if Enrolled):   $5.00   Select:   Item Subtotal:  
$0.00
Band (Mandatory if Enrolled):   $10.00   Select:   Item Subtotal:  
$0.00
Chorus (Mandatory if Enrolled):   $5.00   Select:   Item Subtotal:  
$0.00
Yearbook (Optional):   $25.00   Select:   Item Subtotal:  
$0.00
 
Grade 8
Writing Lab (Mandatory):   $6.00   Select:   Item Subtotal:  
$0.00
Locker Fee (Mandatory):   $1.00   Select:   Item Subtotal:  
$0.00
Intermediate Fitness (Mandatory for all 8th):   $15.00   Select:   Item Subtotal:  
$0.00
Keyboarding (Mandatory for all 8th):   $3.00   Select:   Item Subtotal:  
$0.00
Art (Mandatory if Enrolled):   $5.00   Select:   Item Subtotal:  
$0.00
Band (Mandatory if Enrolled):   $10.00   Select:   Item Subtotal:  
$0.00
Chorus (Mandatory if Enrolled):   $5.00   Select:   Item Subtotal:  
$0.00
Year Book (Optional):   $25.00   Select:   Item Subtotal:  
$0.00
 
Total:
$0.00
 
Parent/Guardian Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone: Email:
Payment Information
Method of Payment:
Convenience Fees: Credit cards: 3% plus $0.50 ($1.50 min)
                    (+1.5% convenience 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:
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 Parent/Guardian Information
Cardholder's Name:
Billing ZIP/Postal Code:

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Schools 800-764-0844 Clinton UT
 
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