SIPlive: Bear River Charter School (L.?)

Student's Name	First Name	Last Name
Student's Name

School Lunch:

Item Subtotal:

$0.00

Spring Trip:

$510.00

Select:

Item Subtotal:

$0.00

Yearbook:

$5.00

Select:

Item Subtotal:

$0.00

After School Club:

Item Subtotal:

$0.00

School Donation:

Item Subtotal:

$0.00

SCA Shirt Orders:

Item Subtotal:

$0.00

SCA Fund Raiser:

Item Subtotal:

$0.00

SCA School Pictures:

Item Subtotal:

$0.00

SCA Green Science Fair:

Item Subtotal:

$0.00

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What do you want this to apply to?				[4]
What do you want this to apply to?				[5]
What do you want this to apply to?				[6]
What do you want this to apply to?				[7]
What do you want this to apply to?				[8]
What do you want this to apply to?				[9]
What do you want this to apply to?				[10]

Other Fees:

Item Subtotal:

$0.00

Please give a description of what you are paying for				[1]
Please give a description of what you are paying for				[2]
Please give a description of what you are paying for				[3]
Please give a description of what you are paying for				[4]
Please give a description of what you are paying for				[5]
Please give a description of what you are paying for				[6]
Please give a description of what you are paying for				[7]
Please give a description of what you are paying for				[8]
Please give a description of what you are paying for				[9]
Please give a description of what you are paying for				[10]

Total:

$0.00

Parent/Guardian Information

First Name:		Last Name:
Phone:
Email:

Payment Information

Method of Payment:

Processing Fee Rates:

Cards: 3% plus $0.50 ($1.50 min)
(4.5% for foreign cards)

eCheck (ACH): $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:
Confirm 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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