CHS Payment Form

Student's Information:                                       * Required

Student # 1 Student # 2 Student # 3
First Name*: First Name: First Name:
Last Name*: Last Name: Last Name:
Student ID #*: Student ID #: Student ID #:
Grade*: Grade: Grade:

Cardholder Information:

First Name:*:
Last Name*:
Address*:
City*:
State*:
ZIP:*:
daytime Phone Number : xxx-xxx-xxxx
Email Address*:
Payment Description:
Payment Amount:  + $ 2.50 Convenience Fee
= Total:  
Comments:

To finish your order, choose a payment method & click on the button below:

Payment by Credit Card Payment by Check