Make a Payment "*" indicates required fields Payment InformationPayment Type*Bill PaymentLEAP Tuition PaymentStructured Teaching Workshop RegistrationHave you been approved for a partial scholarship?* Yes No Tuition Payment (Partial Scholarship)* Price: Payment Amount* Patient Name*Patient Account Number*Student's Name* First Name Last Name Billing InformationTitleMr.MissMrs.MissParent / Guardian's Name*Billing Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Credit Card*Card Details Cardholder Name Total
