Program Registration ~ MOHID ©

Islamic Center of Staten Island

365 VETERANS RD W, Staten Island, New York 10309, USA

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Inara Academy 2022-2023 Registration

10
SEP

12:00 AM

22
JUN

12:00 AM

Program Fee:

One Time: $150.00

1

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Parent First Name*

Parent Last Name*

Parent Phone Number *

Parent Email*

Address *

Student Age*

Student DOB (MM/DD/YYYY)*

Student Grade in School*

Pre-existing health conditions(Diabetes, Asthma, Autism etc)*

How did you hear about our program?*

Use Promo Code: "INARA2" if enrolling 2 students

Use Promo Code: "INARA3" if enrolling 3 students

Use Promo Code: "INARA4" if enrolling 4 students

Will you use our bus service $200/month? (weekend bus full)

WEEKENS ARE FULL - ONLY WEEKDAY CLASSES AVAILABLE

+ Add More Registrants

3

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 Islamic Center of Staten Island consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

Agree Decline

Promotion Code Promotional Price Applied

Since you purchased free Ticket No Payment Required.

Comments

Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

In order to activate the 10% discount for siblings, please type in the promotion code at checkout, INARA2 for 2 kids, INARA3 for 3 kids, INARA4, for 4 kids. By checking this box, I have indicated that I understand these directions

Islamic Center of Staten Island

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Inara Academy 2022-2023 Registration

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Payment Summary

Acknowledgement

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