Program Registration ~ MOHID ©

Islamic Center of Long Island

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

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Registration Open

Saturday 10th - 12th Grades 2023-24

09
SEP

10:00 AM

22
JUN

1:00 PM

Program Fee:

One Time: $632.00

Monthly: $316.00 (Number of Months: 2)

Offering Days: Saturday

Reserved Seats: 10/25

1

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Child's Grade in 2023/24 School Year*

Father's Full Name*

Father's Cell Number*

Mother's Full Name*

Mother's Cell Number*

Emergency Contact Person's Full Name*

Emergency Contact Person's Cell Number*

List any Health Problems and/or Allergies*

Does your Child have a Learning Disability or IEP?*

Can ICLI take Pictures/Video of your Child? *

+ Add More Registrants

3

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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Promotion Code Promotional Price Applied

Since you purchased free Ticket No Payment Required.

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Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

Your payment is complete. By registering , you acknowledge that you will follow all the instructions provided to you by the ICLI for your and other community member's safety.

Islamic Center of Long Island

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Saturday 10th - 12th Grades 2023-24

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