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Search for:
Weekend School Online Payment
Ibrahim Souadda
2019-05-29T18:36:14-04:00
WEEKEND SCHOOL
ONLINE PAYMENT FORM
1
Parents Information
2
3
Dar Al Hijrah Weekend School Winter 2021 Registration for Zoom Classes. All classes this semester will be conducted through zoom. Each class will be two hours and thirty minutes long. Classes are offered on Saturday or Sunday.
If the question does not apply, you may skip if it is not a required section.
Parents' Information
1st Primary Guardian
Name
*
First
Last
Relationship to Child
*
Email
Phone Number
*
2nd Primary Guardian
Name
*
First
Last
Relationship to Child
*
Email
Phone
*
Are you new to the weekend school?
*
Yes
No
How Many Children Are You Enrolling?
*
1
2
3
Emergency Contacts
1st Contact
Click next if not applicable
Name
First
Last
Relationship to Child
Phone Number
2nd Contact
Click next if not applicable
Name
First
Last
Relationship to Child
Phone Number
Child 1
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require
*
Fill N/A if this does not apply to your child
Allergies
*
Fill N/A if this does not apply to your child
Enrollment Tuition Plan
*
Monthly | $50
Full Semester | $200
Total
$0.00
Child 2
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require
*
Fill N/A if this does not apply to your child
Allergies
*
Fill N/A if this does not apply to your child
Enrollment Tuition Plan
*
Monthly | $50
Full Semester | $200
Total
$0.00
Child 3
Good News, your third child is discounted 50% off!
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
Date Format: MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require
*
Fill N/A if this does not apply to your child
Allergies
*
Fill N/A if this does not apply to your child
Enrollment Tuition Plan
*
Discounted price!
Monthly | $25
Full Semester | $100
Total
$0.00
PAYMENT
Name on Card
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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Belarus
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Belize
Benin
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Bolivia
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Bouvet Island
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British Indian Ocean Territory
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Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
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Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Croatia
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Curaçao
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
Equatorial Guinea
Eritrea
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Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
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Lithuania
Luxembourg
Macau
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Madagascar
Malawi
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Malta
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Mauritius
Mayotte
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Nauru
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Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Credit Card
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Expiration Date
Security Code
Cardholder Name
Total
$0.00
Consent
*
I agree to the privacy policy.
I affirm that the above information is complete and true to the best of my knowledge. I verify and agree that my child must abide by the rules of the program and must participate fully in the program. I understand that Summer Camp of DAH reserves the right to request any participant to leave the program if a participant's conduct is determined to be disruptive to the program and fellow registrants. I understand that the organizing institutions, administration, their officials, and staff are not responsible for any injuries or loss of property that may occur. In the case of an emergency where I cannot be contacted, I authorize the administration to seek medical attention and/or administer any needed emergency procedures for the registrant. I also authorize my insurance information to be used and I authorize Dar Al-Hijrah Islamic Center or the insurance company to release any information required to process the claim. In such a case, I understand that I am financially responsible for any due balance. I understand that my child(ren) will not be allowed to begin or continue with the program if payment in full is not submitted prior to the beginning of their first session (or first session of next month).
Signature
*
Type in your name to acknowledge the completion of this application and payment
Parent/Guardian Signature
Date
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
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