Kaironeek University Student Intake Form

PART 1: Personal Information
Full Legal Name

First NameLast Name
Email Address:
Email
Mobile Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth:
Street Address:

Street Address

CityState

Zip CodeCountry
💳 PART 4: Payment & Enrollment Option
IMPORTANT NOTICE:

All payment options will be automatically billed on a recurring basis according to the selected plan. This agreement is governed by the laws of the State of New York
Select your preferred payment option: (Only choose one)

Full Payment – $2,579 Note: This will be billed in full at checkout. A second recurring charge will occur automatically 30 days later unless the account is manually canceled prior.50% Down Payment Plan Note: The down payment is charged immediately, and the remaining balance will be split into monthly installments. Each installment is auto-billed every 30 days from the date of the down payment.
Do you need assistance setting up your payment plan?
Yes   No

Preferred Time for a Payment Setup Call

I understand and agree that my selected payment option will be automatically billed on a recurring basis every 30 days. I acknowledge that this is a legally binding enrollment agreement governed by the State of New York.1*
Should be Empty:

PART 1: Personal Information