Payment - En Avant Academy Of Dance

Class Payment Form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

How many children are you paying for

First Name - Child 1

Last Name - Child 1

Payment for one child

First Name - Child 2

Last Name - Child 2

Payment for SECOND child

First Name - Child 3

Last Name - Child 3

Payment for THIRD child

Sub-Total of Payments

Payment Fee for Purchase of $99 or Less

Fee: $3.00

Payment Fee for Purchase of $100-$175

Fee: $5.00

Payment Fee for Purchase of $176-$249

Fee: $7.00

Payment Fee for Purchase of $250 or more

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Additional Comments

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