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Prince Georges Muslim Association

9150 Lanham Severn Rd, Lanham, Maryland 20706, USA

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PGMA Muslim Youth Soccer League | Winter 2023

17
DEC

03
MAR

Program Fee:

One Time: $165.00

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1 Parent Information

First Name *

Last Name *

Phone Number *

Email Address *

Address1 *

Address2

Country *

State *

City *

Zip Code *

Cell Number

2 Add Participants (Children)

Primary Contact as First Registrant

Registrant Name*

Email Address

Age

Gender

Choose Program

+ Add More Registrants

3 Payment

You can help save us on credit card transaction fees by selecting the eCheck/ACH option. Jazakumullahu khairan!

Payment Method

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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 Prince Georges Muslim Association consent to authorize electronic fund transfer from the account specified for this transaction in the amount specified.

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Since you purchased free Ticket No Payment Required.

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Payment Summary

Program Fee

Total Registrants

Total Cost

Acknowledgement

By registering for this program, you acknowledge that you will follow all instructions provided by the coaches during the course of the MYSL program and that you have read and will abide by the MYSL Liability Waiver available at: https://pgmamd.org/myslwaiver

Prince Georges Muslim Association

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PGMA Muslim Youth Soccer League | Winter 2023

1 Parent Information

2 Add Participants (Children)

3 Payment

Payment Summary

Acknowledgement

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