tuition payment contract
TUITION PAYMENT CONTRACT
Please mail this form directly to the Association office (LHSA, 5401 Lucas & Hunt Road, St. Louis, MO 63121) or deliver to the school office. This form and the Payment Plan Selection Form must be completed for your child’s registration. PLEASE PRINT ALL INFORMATION, except as noted. For questions, please contact Student Billing at 314-‐833-‐2905. All tuition payments must be completed by the end of each school year. Student Name:_____________________________________________________________________________________ School: (Please check one) ___Lutheran North (LHSN) OR ___Lutheran South (LHSS) Name of Person(s) Responsible for Tuition Payment: _______________________________________________________ Email address of responsible person_____________________________________________________________________ Daytime Phone #:________________________________ Evening Phone #______________________________________ Address:___________________________________________________________________________________________ Street City State Zip Relationship to student: ______________________________________________________________________________ % of Tuition to be paid by person listed above:__________ (If less than 100%, please complete the information below your signature.)
PAYMENT RESPONSIBILITY: I accept financial responsibility for the above named student for tuition payments and other fees as assessed. This acceptance applies to all years that my student attends either LHSN or LHSS. I understand failure to make these payments could result in the student being withdrawn from school. I also understand that should my account be sent to a collections agency for failure to pay that I may be responsible for the agency fees/expenses.
_________________________________________________________________________________________________________________ Signature of responsible party (if husband/wife, only one signature required) Soc. Sec # Date
IF THERE IS MORE THAN ONE PAYER, ALL PARTIES MUST COMPLETE A TUITION PAYMENT CONTRACT FORM AND A PAYMENT PLAN SELECTION FORM BEFORE REGISTRATION WILL BE CONSIDERED COMPLETE!
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There are additional parties responsible for tuition payments for this student(s). _______________________________________________________ ______________________________ Name(s) of additional parties % responsible for _______________________________________________________ _______________________________ Relationship to student Phone Number
2015-‐11
Administrative Use Only Entered in BB by: _____________ Date: _______________________
Please mail this form directly to the Association office (LHSA, 5401 Lucas & Hunt Road, St. Louis, MO 63121) or deliver to the school office. This form and the Payment Plan Selection Form must be completed for your child’s registration. PLEASE PRINT ALL INFORMATION, except as noted. For questions, please contact Student Billing at 314-‐833-‐2905. All tuition payments must be completed by the end of each school year. Student Name:_____________________________________________________________________________________ School: (Please check one) ___Lutheran North (LHSN) OR ___Lutheran South (LHSS) Name of Person(s) Responsible for Tuition Payment: _______________________________________________________ Email address of responsible person_____________________________________________________________________ Daytime Phone #:________________________________ Evening Phone #______________________________________ Address:___________________________________________________________________________________________ Street City State Zip Relationship to student: ______________________________________________________________________________ % of Tuition to be paid by person listed above:__________ (If less than 100%, please complete the information below your signature.)
PAYMENT RESPONSIBILITY: I accept financial responsibility for the above named student for tuition payments and other fees as assessed. This acceptance applies to all years that my student attends either LHSN or LHSS. I understand failure to make these payments could result in the student being withdrawn from school. I also understand that should my account be sent to a collections agency for failure to pay that I may be responsible for the agency fees/expenses.
_________________________________________________________________________________________________________________ Signature of responsible party (if husband/wife, only one signature required) Soc. Sec # Date
IF THERE IS MORE THAN ONE PAYER, ALL PARTIES MUST COMPLETE A TUITION PAYMENT CONTRACT FORM AND A PAYMENT PLAN SELECTION FORM BEFORE REGISTRATION WILL BE CONSIDERED COMPLETE!
q
There are additional parties responsible for tuition payments for this student(s). _______________________________________________________ ______________________________ Name(s) of additional parties % responsible for _______________________________________________________ _______________________________ Relationship to student Phone Number
2015-‐11
Administrative Use Only Entered in BB by: _____________ Date: _______________________
