KOM Parent – Student Handbook Agreement Form

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KOM Parent – Student Handbook Agreement Formlcollett@netgalaxy.holdings2020-05-28T11:26:26-04:00

Cardholder's First Name*
Cardholder's Last Name*
Cardholder's E-mail*
Cardholder's Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cardholder's Phone Number
Product/Service (Ex: Monthly Tuition Payment)*
Amount authorized*
Card Type*
- Mastercard
- Discover
- Visa
- AMEX
Card number*
Expiration date (MM/YYYY)*
Recurring Payments Information - I agree for my credit card to be charged the amount above every:*
- Week
- Month
- Quarter
Charge on this date (Ex: first of every month):*
Terms of agreement (For example, cancellations must be received 1 week prior to expected billing date):*
I would like my receipt*
Mailing Address (for receipts)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Authorization to charge credit card*
I agree to the Authorization to charge credit card
I give permission to Clapham Education Group/Charleston Bilingual Academy to charge my card for the following purchases. My card details will be stored in my profile and will only be used for approved purchases.

***I understand the following fees will be charged:

Transfers ACH 1% + 25 cents

Payments by Credit Card 3.4% + 25 cents
Signature
Date
Date Format: MM slash DD slash YYYY

KOM Classes & Workshops

KOM is excited to offer Spanish and Mandarin Immersion Virtual Tutoring to 3-year-olds to adults! Students will engage in small group (3-4 students), dynamic language interaction according to fun themes. Children who live in Charleston, SC can also participate in circle times at our school.

Clapham Group LLC-EIN 47-233 1281 (2014-2017)
Clapham Education Group 501c3-EIN 82-1567491 (2018+).

Charleston Bilingual Academy

Come visit us as we are located at Friendship Baptist Church right off of Park Circle.

843-779-2472
info@charlestonbilingualacademy.org
843-779-2472
5032 Lackawanna Blvd., North Charleston, SC 29405

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