Hifz Summer Camp Registration Form

MASJID FATIMA ALZAHRA

55 Lake Shore Rd , Ronkonkoma , NY 11779

info@masjidfatimaalzahra.org

www.masjidfatimaalzahra.org

(631)-648-0100
Registration Form

First Participant Information Here
Name

First NameLast Name
Date of Birth

MonthDayYear
School Grade
Email
example@example.com

Second Participants Information Here
Name

First NameLast Name
Date of Birth

MonthDayYear
School Grade
Email
example@example.com

Third Participants Information Here
Name

First NameLast Name
Date of Birth

MonthDayYear
School Grade
Email
example@example.com

Fourth Participants Information Here
Name

First NameLast Name
Date of Birth

MonthDayYear
School Grade
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fees Payment
Student Registration Fees
prevnext( X )
Weekly Half day
$100.00 Select Student

Weekly Full day
$175.00 Select Student

Total

$0.00
Type a question*

Dear Parents /Guardians Please sign this waiver with the summer came application . Thank you

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Card Expiration

Security Code

Please click one of the PayPal options to complete payment and submit the form.

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