UT Success Academy

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UT Success Academy Fee Schedule
School fees MUST be paid prior to the start of school

Student's First and Last Name	First Name	,	Last Name
Student's First and Last Name

National Honor Society Dinner (per person):

$15.00

Quantity:

Item Subtotal:

$0.00

Student Council Jacket:

$58.00

Quantity:

Item Subtotal:

$0.00

Science Poster:

$10.00

Quantity:

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:

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*SUCCESS ACADEMY

and the service fee transaction as CBT*SVC FEE SUCCESS ACAD

Submitting ...


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