Program Registration ~ MOHID ©

Program Registration

Program Information

Program Title:

Sunday 7th Grade

Program Start Date:

09/09/2018

Program End Date:

06/23/2019

Program Start Time:

10:00 AM

Program End Time:

1:00 PM

	Seats	Program Fee	Additional Information
		$450.00	Before registering your child, kindly call office and make sure you are an active member. The fee for Non-Members is $500. ($50 additional fee has to be paid) Please Note: Enter your Child's name as Registrant In the Notes box, (under Fee Information) 1. Enter the Date of Birth (DOB) of your Child. 2. Please mention if your child has any allergies or special needs we should be aware of.
Offering Days: Sunday Partial Payment: Y Number of Months: 3 Partial Amount: $150.00

Contact Information

First Name: *

Last Name: *

Address1: *

Address2:

Country: *

State: *

City: *

Zip Code: *

Phone Number: *

Cell Number:

Email Address: *

Payment Information

Payment Method: *

Credit Card

Credit Card Type: *

Name on Credit Card: *

Credit Card Number: *

Expiry Date: *

CVV Code: *

Bank Name:

Name on Account: *

Account Number: *

Routing Number: *

Account Type: *

Recurring:

Recurring Start Date: *

Number of Months: *

For Lifetime:

Consent: *

Do you give Islamic Center of Long Island consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

Agree Decline

Fee Information

Program Fee: *

Promotion Code:

Apply Promotion

Notes:

Please type the word shown below: *

Islamic Center of Long Island

New York

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