Bear River Charter School

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

School Lunch:

Item Subtotal:

$0.00

Fall Trip:

$510.00

Select:

Item Subtotal:

$0.00

Yearbook:

$17.00

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

What do you want this to apply to?

Other Fees:

Item Subtotal:

$0.00

Please give a description of what you are paying for

Total:

$0.00

Parent/Guardian Information

First Name:	Last Name:
Address:
Address:
City:	State/Province:	ZIP/Postal Code:
Phone:
Email:

Payment Information:

Processing Fee Rates:
Cards:	3% plus $0.50 ($1.50 min) (1.5% surcharge 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:

Change Payment Method

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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