Midwest Bible Training Center

Virtual Academy

3303 Homer Adams Parkway, Alton, IL 62002 Telephone: (618) 465-5433
www.mbtc2000.org

ENROLLMENT AGREEMENT

Please print your name exactly as you would like it to appear on your High School Diploma:

 Name:                                                                                    

 Mailing Address: City:                                            

Phone #: _                                                      Other Phone #:                                           

Date of Birth:                        Birthplace: (CITY/ST).                                                                                           ,           

Please select one of the following Payment Plans:  (CHECK ONE)

q  PLAN "A" Paid in Full: ($450.00) (1 subject each additional subject is $300.00)

q  PLAN "B" Monthly Plan: ($505.00) (1 subject each additional subject is $300.00)

I have enclosed a down payment of $               ($125 or more) and I will pay $                  ($50 or more) per month.

Please indicate your method of Payment:

q Money Order             q Visa           q Master Card                q American Express           q Check              q Cash

If you are paying by Check or Money order, please make payable to Midwest Bible Training Center

If paying by Credit Card, please complete the following information: Amount to be charged: $                  

                                                                                                                                                                                                           

                                Credit Card Number                            Expiration Date                             Signature of Cardholder

 

Note: MBTC is a private, non-public High School.. If you are under the age of 18 years, a parent or guardian's signature of approval is required. I hereby grant permission to the above named individual to enroll in this high school program.

Student Signature:                                                                          Date:      /     /     

Parent/Guardian/Guarantor Signature:                                                               Date:          /       /