Virtual Summer Camp About the Program 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 Boy Girl Child 2 Last Name Child 2 First Name Child 2 Birthdate Child 2 Gender Boy Girl Child 3 Last Name Child 3 First Name Child 3 Birthdate Child 3 Gender Boy Girl Child 4 Last Name Child 4 First Name Child 4 Birthdate Child 4 Gender Boy Girl Child 1 Registration Month July Child 2 Registration Month July Child 3 Registration Month July Child 4 Registration Month July Allergy Information By submitting this form, I acknowledge that Virtual Summer Camp cost of $250 per month 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. Proceed to Payment