Quran Hifz Program Registration Form ( Monday - Thursday)
Al-Minhal Academy of Washington Township. Please fill out this form to the best of your ability. If you are enrolling more than one child, kindly fill out a separate form.
Student Name
*
First Name
Last Name
Age
*
DOB
*
-
Month
-
Day
Year
Gender
*
Please Select
Male
Female
N/A
Public School Grade
*
Parent/Guardian Information
Parent/Guardian 1:
*
Relationship to Student:
*
Parent/Guardian 2:
Relationship to Student:
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email Address 1
*
example@example.com
Medical Information
Any Medical Problems or Needs
Allergies
Emergency Contact Number
Name
*
Phone Number
*
Please enter a valid phone number.
Payments
*
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( X )
1st Child Fee
One Time Registration Fee
$
100.00
On Going Children
$
80.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Register Class
Should be Empty: