Program Registration ~ MOHID ©

Convergence Culturelle Africaine

CP 332 Aylmer, Gatineau, Quebec J9H5E6, CA

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Donations Tickets Pledge Program Registration

LA DAARA de la CCA

17
SEP

23
JUN

Program Fee:

One Time: $285.00

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1 Information du Parent

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

Province *

City *

Postal Code *

Cell Number

2 Ajouter un enfant

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

Age*

Gender*

+ Add More Registrants

3 Paiement

Payment Method

Credit/Debit Card

Name on Credit Card *

Credit Card Number*

Expiry Date*

CVV Code*

Bank Name

Name on Account *

Account Number*

Routing Number*

Account Type*

Monthly Recurring

Recurring Start Date*

Number of Months*

For Lifetime

Please note: You will incur a $1 charge if the recurring start date is not current date in order to verify the payment details provided. This charge will not be credited back to your account and you will receive a test transaction receipt for this amount.

Consent * Do you give Convergence Culturelle Africaine consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Promotion Code Promotional Price Applied

Since you purchased free Ticket No Payment Required.

Comments

Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

By registering , you acknowledge that you will follow all the instructions provided to you by the Masjid for your and other community member's safety

Convergence Culturelle Africaine

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LA DAARA de la CCA

1 Information du Parent

2 Ajouter un enfant

3 Paiement

Payment Summary

Acknowledgement

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