Program Registration ~ MOHID ©

1 Contact Information

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Last Name *

Phone Number *

Email Address *

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Address2

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City *

Zip Code *

Cell Number

2 Add Registrants

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Registrant Name*

Email Address

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Child's First and Last Name*

Child's Age*

Allergies (Yes or No)*

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3 Payment

Monthly Recurring

Recurring Start Date*

Number of Months*

For Lifetime

Please note: You will incur a $1 charge if the recurring start date is not current date in order to verify the payment details provided. This charge will not be credited back to your account and you will receive a test transaction receipt for this amount.

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Credit Card Number*

Expiry Date*

CVV Code*

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Routing Number*

Account Type*

Consent * Do you give Islamic Cultural Association consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Islamic Cultural Association

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Tafakor Meals November 25- May26

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Islamic Cultural Association

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Tafakor Meals November 25- May26

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2 Add Registrants

3 Payment

Payment Methods

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Payment Summary

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