WIS registration Partial Amount

Weekend Islamic School – Partial Amount

Registration for WIS at HCIC

Part I – Parent information
Father's name*
First Last
Father's Cell phone*
Mother's name*
First Last
Mother's Cell phone*
Home mailing address*
Street Address Address Line 2 City State ZIP Code
Home Phone, if there is one
Primary Email address*
This email will be used to send any WIS announcements such as Mid-term & Final exam, Quran competition, school closures, etc…
Enter Email Confirm Email
Part II – Emergency Contact
Emergency Contact Name*
Please list someone to call in case of an emergency if we are unable to reach either parents.
First Last
Emergency Contact Phone
Please put the best phone number for us to call
Emergency contact relationship to child/children*
Declaration
I hereby authorize the BIS-WIS to take my child/children to a licensed physician or medical center in the event of an emergency in which neither parents can be reached.
- Check here to accept
Part III – Student information
How many children are you registering?*
Student # 1*
First Last
Student # 1 Date of Birth*
MM slash DD slash YYYY
Student # 2*
First Last
Student # 2 Date of Birth*
MM slash DD slash YYYY
Student # 3*
First Last
Date of Birth*
MM slash DD slash YYYY
Student # 4*
First Last
Date of Birth*
MM slash DD slash YYYY
Student # 5*
First Last
Date of Birth*
MM slash DD slash YYYY
Part IV – Fees
1 child – $300.00 2 children – $400.00 3 children – $500.00 4 children – $600.00 5 children – $700.00
Total
$ 0.00
Part V – Payment
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Weekend Islamic School – Partial Amount

Part I – Parent information

Part II – Emergency Contact

Part III – Student information

Part IV – Fees

Part V – Payment