MASJID NOOR LONG ISLAND
11032 Park Ave, Huntington, NY 11743
feedback@masjidnoorli.net
www.masjidnoorli.net
(631) 683-4185
MAKTAB SCHOOL
Parents Information
Father Name
First Name
Last Name
Father Mobile Number
*
Please enter a valid phone number.
Father Email
*
example@example.com
Mother Name
First Name
Last Name
Mother Mobile Number
Please enter a valid phone number.
Mother Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child 1 Information Here
Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Child 2 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Child 3 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Child 4 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Fees Payment
Monthly Recurring Payments.
*
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next
( X )
1st Children
$
75.00
for each
month
2nd Children is 25% Discount
$
135.00
for each
month
3rd Children 50% Discount
$
195.00
for each
month
4th Children 50% Discount
$
255.00
for each
month
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: