APPLICATION FORM
LIMRA ISLAMIC CENTER
Student Details
*
First Name
Last Name
Parent Details
*
First Name
Last Name
Age
Gender
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Choose 3 or 5 days for your classes (Quran or Islamic Studies) - Fees varies
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many days you want for your child classes per week
Please Select
3 days
5 days
Select the Course
*
Please Select
Quran - Nazira
Islamic Studies
Quran and Islamic Studies
Namaz Course
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How many kids
Please Select
1
2
3
4
Course Fee: Zelle the payment to 312-545-2033
*
Please Select
3 days - $50
5 days - $100
payment based on days selected
Submit
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