Program Registration ~ MOHID ©

Islamic Center of Long Island

835 Brush Hollow Road, Westbury, New York 11590, USA

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Registration Open

Womens Fitness - Evening Session

03
DEC

6:30 PM

26
DEC

7:30 PM

Program Fee:

One Time: $99.00

Offering Days: Tuesday, Thursday

Reserved Seats: 9/20

1 Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2 Add Registrant

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Participant's Full Name*

Emergency Contact Name*

Emergency Contact Number

+ Add More Registrants

3 Payment

Payment Method

Credit/Debit Card

Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

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.

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.

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Since you purchased free Ticket No Payment Required.

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Payment Summary

Program Fee

Total Registrants

Total Cost

Islamic Center of Long Island

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Womens Fitness - Evening Session

1 Contact Information

2 Add Registrant

3 Payment

Payment Summary

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