Hifz Summer Camp Registration Form

MASJID NOOR LONG ISLAND

11032 Park Ave, Huntington, NY 11743

feedback@masjidnoorli.net

www.masjidnoorli.net

(631) 683-4185
Registration Form

Parents Information
Father Name*

First NameLast Name
Father Mobile Number*
Please enter a valid phone number.
Father Email
example@example.com
Mother Name*

First NameLast Name
Mother Mobile Number
Please enter a valid phone number.
Mother Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Child Information
Student Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
School Grade
Email

Fees Payment

Select Fee Package*

Student Registration Fees

$400.00

Siblings Discount	Quantity	Price
One Child		$400.00
Two Children		$775.00
Three Children		$1,150.00
Four Children		$1,525.00

Item subtotal:$0.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: