LASD SACC Payment Form
Week Of
-
Month
-
Day
Year
Date
Parent Name
First Name
Last Name
Parent Email
example@example.com
Child Name 1
First Name
Last Name
Child Name 2
First Name
Last Name
Child Name 3
First Name
Last Name
Child Name 4
First Name
Last Name
Notes to SACC Staff
SACC Options: Check the box for the services requested, and then enter the number of students for each day as needed.
prev
next
( X )
Morning Only
$
10.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
Afternoon Only
$
10.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
Morning & Afternoon
$
20.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
In-Service / Vacation / Snow Day
$
25.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
Early Dismissal
$
15.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
Summer SACC - Daily
$
50.00
Days of the Week
Students
Monday
Tuesday
Wednesday
Thursday
Friday
Summer SACC - Weekly
$
200.00
Students
Flat Convenience Fee
Flat convenience fee payable to credit card processing company, in addition to calculated convenience fee below.
$
0.30
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: