Secondary Extended Care Contract Date* MM slash DD slash YYYY Parent/Guardian Name* First Last Email Plan Selection (Student 1)1. Student Name* First Last 1. Student Grade*Choose One6th7th8th9th10th11th12th1. Select PM Plan #*Select OneAS5AS4AS3AS2AS1Plan Selection (Student 2)2. Student Name First Last 2. Student GradeChoose One6th7th8th9th10th11th12th2. Select PM Plan #Select OneAS53AS43AS33AS23AS13Plan Selection (Student 3)3. Student Name First Last 3. Student GradeChoose One6th7th8th9th10th11th12th3. Select PM Plan #Select OneAS53AS43AS33AS23AS13Plan Selection (Student 4)4. Student Name First Last 4. Student GradeChoose One6th7th8th9th10th11th12th4. Select PM Plan #Select OneAS53AS43AS33AS23AS13PaymentI understand that my FACTS account with be drafted for the amount corresponding to the Plan # I have chosen.* I understand and give my permission. Δ
