MIC Quran Program Registration
Please Pay Fees at https://us.mohid.co/tn/memphis/micc/masjid/online/registration/index
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Parent/Guardian Information
Relationship *
Name *
Address (Street, City, State, Zip  Code) *
Cell Phone *
Home Phone *
Email (Preferably Gmail) *
Emergency Contact Information
Full Name *
Phone *
Relationship to Student *
Student Information
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Gender *
Session Day & Time *
Health Information
Injuries/Illness/Medical Needs/Allergies *
Medication & Frequency *
Are you registering more than one student? *
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