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high school credit card

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					                                  College in the High School Credit Card Payment
                                                       (Attach to registration form)


_______________________________________________________________________
NAME OF STUDENT                                                                                                  STUDENT’S SOCIAL SECURITY NUMBER


_______________________________________________________________________
NAME OF CARDHOLDER



_______________________________________________________________________
CARDHOLDER’S ADDRESS                                                               CITY                                         ST                            ZIP



_______________________________________________________________________
PHONE:                 (DAY)                                                                                     (EVENING)


Paying by: VISA                       M/C                                Discover                 (Only Visa, Mastercard or Discover cards are accepted)

Authorized Amount: ______________

Card # ___________________________________________________________________________ Exp. Date: ____________


Name as it appears on card: ________________________________________________________ V-code *: _______________


Signature: ___________________________________________________________________________

         The V-code is the last 3 digits of the number located on the back of your Visa/MasterCard. Banks now require the V-code in order to process your credit card. This
         new policy has been implemented in response to the increasing threat of credit card fraud. This policy is in place to protect you!

                                          This document will be promptly shredded after payment has been processed.


Each 5-credit College in the High School course is $180.00.