Bear River Charter School
Student's NameFirst NameLast Name
School Lunch:   $   Item Subtotal:  
Fall Trip:   $510.00   Select:   Item Subtotal:  
Yearbook:   $17.00   Select:   Item Subtotal:  
After School Club:   $   Item Subtotal:  
School Donation:   $   Item Subtotal:  
SCA Shirt Orders:   $   Item Subtotal:  
SCA Fund Raiser:   $   Item Subtotal:  
SCA School Pictures:   $   Item Subtotal:  
SCA Green Science Fair:   $   Item Subtotal:  
What do you want this to apply to?
Other Fees:   $   Item Subtotal:  
Please give a description of what you are paying for
Parent/Guardian Information
First Name: Last Name:
Payment Information:
Processing Fee Rates:
Cards:3% plus $0.50 ($1.50 min)
(1.5% surcharge for foreign cards)
Method of Payment:
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Name on Account:
Routing Number:
Account Number:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
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Your statement will describe your payment as

CBT*BEAR RIVER CHTR S’ and the service fee transaction as ‘CBT*SVC FEE BEAR RIVE’

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