Program Registration ~ MOHID ©

Islamic Center of Staten Island

365 VETERANS RD W, Staten Island, New York 10309, USA

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Quran Summer Camp 2020

06
JUL

7:00 AM

31
JUL

6:00 PM

Program Fee:

One Time: $1,000.00

Offering Days: Monday, Tuesday, Wednesday, Thursday, Friday

1 Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2 Add Registrants

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Parents Full Name*

Emergency Contact #1 Name*

Emergency Contact #1 Number*

Emergency Contact #2 Name*

Emergency Contact #2 Number*

DOB (dd/mm/yyyy)*

Grade (Entering Sept. 2020)*

Food Allergies / Dietary Restrictions

Pre-Existing Health Conditions (Disabilities Included)

Bus? (Yes or No) (Bus Fee will be paid separately)

Use Promo Code: *CH2* if signing up 2 children

Use Promo Code: *CH3* if signing up 2 children

Use Promo Code: *CH4* if signing up 2 children

+ Add More Registrants

3 Payment

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazak'Allah!

Payment Method

eCheck/ACH titleIcon

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 Staten Island consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

Agree Decline

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

Islamic Center of Staten Island

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Quran Summer Camp 2020

1 Contact Information

2 Add Registrants

3 Payment

Payment Summary

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