Full-Time Taḥfīẓ al-Qur'ān

1

Parent & Student Information

2

Payment Details

Student Information:

 

Student Legal Name *

Alberta Health Card Number

Student Date Of Birth

Student Medical Condition

 

Parent/Guardian Contact Information:

 

Contact Information Parent/Guardian *

–Select Option– Father Mother Guardian

First Name *

Email Address *

Address – Contact

Address Line 1

Address Line 2

City

Province

Postal Code

Last Name *

Phone Number *

Student Lives With

Occupation

WhatApp Number

 

Emergency Contact Information:

 

Full Name – Emergency Contact *

Address – Emergency Contact

Address Line 1

Address Line 2

City

Province

Postal Code

Email Address – Emergency Contact

Phone Number – Emergency Contact

Phone Number – Emergency Contact

Relationship With Student

 

Pre-Authorization Payment Form:

 

Last Name – Pre-Authorization *

Phone Number – Pre-Authorization

Address – Pre-Authorization

Address

Address Line 2

City

Province

Postal Code

First Name – Pre-Authorization *

Email Address – Pre-Authorization *

Credit Card Expiry Date – Pre-Authorization *

Payment – Select

–Select Option– VISA MasterCard AMEX Debit

Date Form Signed

Select Payment Method

• 
• 

Direct bank transfer

Add into System

Amount *

$

$0 for each month, for 120 installments

Submit Please Wait…

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