MASJID NOOR LONG ISLAND
11032 Park Ave, Huntington, NY 11743
feedback@masjidnoorli.net
www.masjidnoorli.net
(631) 683-4185
MAKTAB PROGRAM
Date: September 4th (First Day of Classes) Time: 5PM - 7PM
Parents Information
Parents Name
First Name
Last Name
Parents Mobile Number
*
Please enter a valid phone number.
Parents 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
School Grade
Completed Last Maktab Class
Please Select
Sister Sana
Sister Asma
Sister Hafsa
Hafiz Safa
Hafiz Salman
Hafiz Huzaifa
New Student
Child 2 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
School Grade
Completed Last Maktab Class
Please Select
Sister Sana
Sister Asma
Sister Hafsa
Hafiz Safa
Hafiz Salman
Hafiz Huzaifa
New Student
Child 3 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
School Grade
Completed Last Maktab Class
Please Select
Sister Sana
Sister Asma
Sister Hafsa
Hafiz Safa
Hafiz Salman
Hafiz Huzaifa
New Student
Child 4 Information Here
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
School Grade
Completed Last Maktab Class
Please Select
Sister Sana
Sister Asma
Sister Hafsa
Hafiz Safa
Hafiz Salman
Hafiz Huzaifa
New Student
Fees Payment
20% discount for every additional child. (Monthly Recurring Payments. )
*
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next
( X )
1st Children
$
75.00
for each
month
2nd Children
75+60=135
$
135.00
for each
month
3rd Children
75+60+60=195
$
195.00
for each
month
4th Children
75+60+60+60=255
$
255.00
for each
month
Email
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: