Miscellaneous Payments Form (Clubs, Lost Materials, etc.) Miscellaneous Payments "*" indicates required fields Student Name* First Last Grade Level*PreschoolKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Parent Name* First Last Email* This payment is for:* Auction Donation Club Hot Lunch Jogathon Lost / Damaged Material Tuition (previous year) XDC Other *Please clarify what exactly you are making payment for (name of club, item lost/damaged etc.). Payment Amount Fees (30¢ + 2.2%) Price: $0.00 Total Credit CardCard Details Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please note: Your Zip Code must match your credit card billing Zip Code or your transaction will not go through. 24124
