Program Registration ~ MOHID ©

Worcester Islamic Center

248 East Mountain Street, Worcester, Massachusetts 01606, USA

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Daily Quran School

04
JUL

01
JAN

Program Fee:

One Time: $1,800.00

Monthly: $150.00 (Number of Months: 12)

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1 Contact Information

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2 Add Registrants

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Your Childs Full Name

Choose Qaida, Naazirah, and Memorization

+ Add More Registrants

3 Payment

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazak'Allah!

Payment Method

eCheck/ACH titleIcon

Credit/Debit Card

Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Monthly Recurring

Recurring Start Date*

Number of Months*

For Lifetime

Please note: You will incur a $1 charge if the recurring start date is not current date in order to verify the payment details provided. This charge will not be credited back to your account and you will receive a test transaction receipt for this amount.

Consent * Do you give Worcester Islamic Center consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Promotion Code Promotional Price Applied

Since you purchased free Ticket No Payment Required.

Comments

Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

By registering , you acknowledge that you will follow all the instructions provided to you by the Masjid for your and other community member's safety

Worcester Islamic Center

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Daily Quran School

1 Contact Information

2 Add Registrants

3 Payment

Payment Summary

Acknowledgement

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