After School - Community Center of Masjid Jafar

Registration

Father's Last Name

Father's First Name

Father's Phone Number

Mother's Last Name

Mother's First Name

Mother's Phone Number

Father's Email

Mother's Email

Payment Email

Address Line 1

Address Line 2

City

Zipcode

Emergency Last Name

Emergency First Name

Emergency Phone Number

Child 1 Last Name

Child 1 First Name

Child 1 Birthdate

Child 1 Gender

Child 2 Last Name

Child 2 First Name

Child 2 Birthdate

Child 2 Gender

Child 3 Last Name

Child 3 First Name

Child 3 Birthdate

Child 3 Gender

Child 4 Last Name

Child 4 First Name

Child 4 Birthdate

Child 4 Gender

Allergy Information

By submitting this form, I acknowledge that After School cost of $120 per student will be owed to Al-Rahmah Islamic Center Inc DBA Masjid Jafar and that needs to be paid in advance to reserve the seat at the Summer Camp.