Summer Camp - Community Center of Masjid Jafar

REGISTRATION & PAYMENT

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 Summer Camp cost of $200 per child 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.