MYACD Registration Form
Muslim Youth Association of Capital DistrictAl-Arqam Campus
Student's Information
Student's Name
*
First Name
Last Name
Student's Phone Number
*
Please enter a valid phone number.
Student's Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Selection
*
Please Select
Youth Seminary 1
Youth Seminary 2
Parent's Information
Father's Name
*
First Name
Last Name
Father's Phone Number
*
Father's Email
*
Mother's Name
*
First Name
Last Name
Mother's Phone
*
Mother's Email
*
Configurable list
*
Type a question
Payment Information
Fees ($50 per month per child)
*
prev
next
( X )
MYACD Monthly Fee
USD
for each
month
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Parental Consent
Consent
*
I/We, as parent(s) of the student filling this form, agree to his/her participation in the Youth Program
Parent Signature
*
Submit
Should be Empty: