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Bnos Chabad

High School Extracurricular Program Payment Form
Number of Students*

1 student $2502 students $5002 students (10% discount) $4503 students ( 10% discount) $675
Name of Student #1
First Name Last Name
Name of Student #2
First Name Last Name
Name of Student #2
First Name Last Name
Name of Student #3
First Name Last Name
Optional Donation

$180$100$72$54$36$18
Total

$0.00

I would like to pay today:Full amount50% minimum: $0.00 $
Yes, I'd like to donate the cost of processing this transaction by adding 3%
Please Note: If choosing to pay partial amount today. The second payment will be charged to your credit card on January 15, 2025.

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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High School Extracurricular Program Payment Form