SIPlive: Bear River Charter School (L-)

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

School Lunch:

Item Subtotal:

$0.00

Spring Trip:

$450.00

Select:

Item Subtotal:

$0.00

Yearbook:

$5.00

Select:

Item Subtotal:

$0.00

SCA Fund Raiser:

Item Subtotal:

$0.00

School Donation:

Item Subtotal:

$0.00

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:

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:

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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