Tuition and Fee Payment Form

Tuition and Fee Payment Form
First name*
Last name*
Phone Number*
Email*

Confirmation Emailexample@example.com
Course/Program
Class Dates

MonthDayYear
Begin Date
MonthDayYear
End Date
Indicate class times (Day Class, Evening Class, Weekend Class)*
Choose from dropdown
ITEMS AVAILABLE FOR PURCHASE (Choose applicable item by clicking the box)
prevnext( X )
Full TuitionFull Tuition Cost
$675.00



Payment Plan (50% Down)Down Payment
$337.50



Registration FeeRequired - (non-refundable)
$50.00



Criminal Background Check(If completed by GraceMed)
$25.00



Uniform Package(Student is responsible for their own matching uniform if opting out of package)
$45.00



BP Cuff/Stethoscope Set(Optional)
$40.00



TB Test(If purchased from GraceMed)
$40.00



CPR Class (on site)(If registered by GraceMed Academy Staff)
$60.00



Drug Test (If completed by GraceMed - onsite)
$25.00



ATB Test(Required if No High School or GED Transcript)
$15.00



Total

$0.00
Total Amount of Tuition and Fees Owed
FEES SUBJECT TO CHANGE WITHOUT NOTICE
Installment Agreement

Installment payments are set up based on the course program and the time that it takes to complete. After paying the required down payment of 50%, students may make weekly installments on the balance. The balance will be divided into three or four weeks of class (depending on the class) and this will be the weekly payment. A breakdown of the weekly fee will be provided to the student. Installments are due on Monday of each week unless other arrangements have been made and are in writing. If, at any time, the student does not make the weekly payment by the due date, he/she will not be allowed to attend class until the account is brought up to date. The final payment of the account balance will be due on Monday prior to the first day of clinical. No student will be allowed to complete the class, go to an externship (clinical) or take the state examination for certification if all payments are not completed. All students choosing this option MUST complete and sign a Student Installment Request and a Payment Agreement Contract.
I have read the Installment Agreement and understand my payment responsibilities.

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Select your payment option by signing your initials and inserting the appropriate amounts. Choose one or the other.
Option #1 Initials I will pay the full amount of Amount prior to the first day of class.
Option #2 Initials I will pay 50% down, and then make (3) weekly payments of Amount .
Students Printed Name
Students Signature

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Todays Date

MonthDayYear
Date
Payment Methods Accepted:

Cash, Cashier's Check, Money Order, Debit/Credit Card

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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