Payment Application 1:1 Fees
Please answer the following questions honestly and accurately to the best of your knowledge. The information provided will be kept confidential and anonymous and will only be used to determine eligibility for this service, and or to set up an agreed on payment plan. All submissions will be independently verified to ensure accuracy of eligibility.
Parent/Guardian First and Last Name *
Your answer
Current Street Address *
Your answer
Current Email of Parent *
Your answer
Parents Phone Number *
Your answer
Students First and Last Name *
Your answer
Students Grade *
My Student Owes *
Your answer
I understand that my student will be allowed to check out the device after two of the payments have been made on time *
Required
I agree that if a payment is missed the device will be returned to the library and remain there until the payment(s) have been completed for this debt. *
Required
I agree your my student will have to use the device in the building, but not be allowed to take it anywhere else. Please remember until the yearly Tech Insurance Fee is paid you are 100% responsible for any or all damages to the device *
Required
2nd Student First and Last Name
Your answer
2nd Student Grade enrolled in
2nd Student Owes
Your answer
3rd Student First and Last Name
Your answer
3rd Student Current Grade
3rd Student Owes
Your answer
Total amount owed for student(s) *
Your answer
Payment Options *
I agree to make a $***** payment *
Required
My payment will be due on ********* of each month *
Your answer
Once your form is submitted, the approval process may take up to two business days. Once approved an email will be sent to the address you filled in above, with the start date and amount. Type name below *
Your answer
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