Auto-Pay by Installments Authorization

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Family Information

Type the letters below to prevent spamming: *
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First Name *

Middle Initial

Last Name *

Mailing Address *

City *

State *

Zip Code *

Main Phone Number: *

Type: *

Alternate Phone Number

Type

Email Address *

Student Information

First Student FName: *

First Student LName: *

Current Gr. *

Plan *

Installment *

Second Student FName:

Second Student LName:

Current Gr.

Plan

Installment

Third Student FName:

Third Student LName:

Current Gr.

Plan

Installment

Fourth Student FName:

Fourth Student LName:

Current Gr.

Plan

Installment

Full-Time Monthly Payment Options: (Elementary - 4-5, Above 5 extra; High School 4-6, Above 6 extra)

Quantity: Monthly

	Elementary Plan 1 - $160 ea
	Elementary Plan 2 - $95 ea
	Elementary Plan 3 - $95 ea
	High School Plan 1 - $195 ea

Quantity: Quarterly

	Elementary Plan 1 - $385 ea
	Elementary Plan 2 - $235 ea
	Elementary Plan 3 - $235 ea
	High School Plan 1 - $450 ea

Quantity: Semester

	Elementary Plan 1 - $760 ea
	Elementary Plan 2 - $460 ea
	Elementary Plan 3 - $460 ea
	High School Plan 1 - $895 ea

Part-Time or Extra Course Monthly Payment Options:

Select number of single/extra courses:

Quantity: Full-year course

	Elementary - $35 for 10 months
	High School - $45 for 10 months

Quantity: Semester course

	Elementary - $35 for 5 months
	High School - $45 for 5 months

Credit Card Recurring Payment Option:

Exact Cardholder Name *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CSV (last 3 digits on the back of Visa or MC, or 4 digits on front of AMEX) *

Street Address where cardholder receives the statement or bill *

Zip Code *

Preferred Due Date: *

Authorization:

Completion of this form authorizes payment and committment to Odyssey Academy according to the installment terms selected above. Full-year enrollment requires 10 monthly installments; half-year enrollment requires five. This may be adjusted based upon enrollment date and number of courses. ALL INSTALLMENTS WILL BE CHARGED TO YOUR CREDIT CARD or DEBITED FROM YOUR BANK ACCOUNT, if your debit card has a credit card emblem. You are authorizing payments for all remaining deferred payments to be debited on the scheduled monthly date chosen below.

Debit or credit cards must not expire before the term of this contract i.e. August 2014.

Withdrawal Policy:
Withdrawal still requires full payment through the end of the semester in which the student withdraws. For example, your student begins in September and withdraws in November. You have obligated payment for all monthly payments for the entire semester.

Non-Payment:
Odyssey Academy reserves the right to disable student access should any of your payments be declined. Access will remain disabled until payment arrangements are made.