Evening Maktab / Evening Quran Class Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Parent/Guardian Contact InformationParent 1’s Name *FirstMiddleLastPhone *Email *Parent 2’s NameFirstMiddleLastPhoneEmailMailing Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEMERGENCY CONTACTName *FirstMiddleLastPhone *Emergency contact Relationship to Child * Student(s) Information Full Name of Child *FirstMiddleLastGender *MaleFemaleDate Of Birth *School Grade Level (Numerical Value Only) Allergies (Write NONE for no allergy) Has the child attended any other Islamic School/Weekend Program before?YesNo Has the child attended any MSMC educational program before?YesNoDoes the child requires special accommodation?Yes (If Yes pleases Describe below)NoDescribe here special accommodation*.Authorization and Acknowledgement:Please check *AgreeMedical Consent: :Please check *AgreePhotography Release:Please check *Agree Add More Students Remove This Entry Tuition FeesNumber Of Children *1 (one) Child2 (two) Children3 (three) Children4 ( four) Children1 (one) Child *One time payment - $600.00Half-Year Payment - $300.002 (two) Children *One time payment - $1,200.00Half-Year Payment - $600.003 (three) Children *One time payment - $1,800.00Half-Year Payment - $900.004 (Four) ChildrenOne time payment - $2,400.00Half-Year Payment - $1,200.00Payment Method *Cash (Require in-person payment)Check (Require in-person payment)Credit CardRegistration Fee (One Time charge ) *Price: $0.00For Members Only (Coupon Code) Apply Transaction FeePrice: $0.00( Non-applicable on cash/check payment method )Total$0.00Stripe Credit Card *Submit
