Tuition and Fee Payment Form

First name*

Last name*

Phone Number*

Email*

Confirmation Emailexample@example.com

Course/Program

Class Dates*

Begin Date

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)

Full TuitionFull Tuition Cost

$725.00

Payment Plan (50% Down)Down Payment

$362.50

Registration FeeRequired - (non-refundable)

$50.00

Criminal Background Check(If completed by GraceMed)

$25.00

BP Cuff/Stethoscope Set(Optional)

$45.00

Drug Test (If completed by GraceMed - onsite)

$25.00

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

$40.00

Total

$0.00

Total Amount of Tuition and Fees Owed

Students who choose to purchase uniforms prior to orientation – the uniforms must be TEAL color ONLY. Students purchasing uniforms through GraceMed's chosen vendor, indicate size. You will pay $50 to the vendor (K & H Scrubs) at orientation.

Will you be taking CPR class on site through GraceMed?

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.

Initial Here

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 beginning the 1st week of class in the amount of Amount .

Students Printed Name

Students Signature

Todays Date

Date

Payment Methods Accepted:

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

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.