Registration Form - ICN Evening Quran School
Father's Name
*
First Name
Last Name
Father's Phone Number
*
-
Area Code
Phone Number
Mother's Name
*
First Name
Last Name
Mother's Phone Number
*
-
Area Code
Phone Number
Primary Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Contact
*
First Name
Last Name
Phone Number
*
Doctor Contact
*
First Name
Last Name
Phone Number
*
I / hereby grant permission to Islamic Center of Naperville, or its authorized agent(s) to seek medical help for my/our child/ward in case of emergency when for reason beyond their control the authorized person(s) stated above cannot be reached
*
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Students Registered
*
Select number of Students Enrolled
*
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ICN Evening Quran School One Student
$
60.00
for each
month
ICN Evening Quran School Two Students
$
120.00
for each
month
ICN Evening Quran School Three Students
$
180.00
for each
month
ICN Evening Quran School Four Students
$
240.00
for each
month
ICN Evening Quran School Five Students
$
300.00
for each
month
Subscription ICN Evening Quran School
Duration of subscription to the program per student.
$
60.00
for each
month
Credit Card
Submit
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