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Membership Form
Head of Household Information
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Address Line 2
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Family Information
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Please choose if you are applying for a membership for yourself, or as Married, for you and your spouse
Will you be adding additional family members (ages 18+) to the membership?
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How many additional family members will you be adding to this membership?
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Please enter a number from
1
to
10
.
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Name of additional family member
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Male
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Email
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Phone
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Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
(Required)
First
Last
Gender
(Required)
Male
Female
Email
(Required)
Phone
(Required)
Name of additional family member
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First
Last
Gender
(Required)
Male
Female
Email
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Phone
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References
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Which membership plan would you like to subscribe to?
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Annual Individual Membership Fee
Price:
Annual Couple Membership Fee
Price:
Annual Membership Fee of Additional Family Members (Ages 18+)
Price:
$0.00
Total Annual Membership Fee
Lifetime Individual Membership Fee
Price:
Lifetime Couple Membership Fee
Price:
Lifetime Membership Fee of Additional Family Members (Ages 18+)
Price:
$0.00
Total Lifetime Member Fee
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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
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Month
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02
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04
05
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Year
Year
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Security Code
Cardholder Name
Consent
(Required)
I agree to the privacy policy. I have read and accepted the Dar Al Hijrah Policies associated with this application
The membership application will not be processed until the appropriate fees are paid
Rules & Regulations:
Applicant must be a Muslim who is 18 years of age or older.
Applicant must be a resident of Washington DC Metropolitan Area.
Applicant and any additional family members must enclose a photocopy of driver licenses and/or State ID.
In event of a change of address, member will notify Dar Al Hijrah Islamic Center of the new address within 30 days.
Applicant agrees to abide by the constitution of Dar Al Hijrah Islamic Center.
Applicant by signing the application, agrees to release Dar Al Hijrah Islamic Center, its Directors, Officers, Employees, and Agents from any claims, demands of action applicant may have against Dar Al Hijrah as a result of omission, rejection, suspension, or termination of applicant’s membership.
