Ummah Fit Custom Payment Form

This form requires prior approval before use. Please speak to IOK Academy Admin's before proceeding.

I understand the above:

Yes

How many students are you registering to the Ummah Fit Program?

Student Information

Add the student's info and select the session you'd like to register them for. If you would like to register more than 3 students, please complete another form submission.

First Student Info

First Name

Last Name

Gender

Male

Female

Date of Birth

Grade

Second Student Info

First Name

Last Name

Gender

Male

Female

Date of Birth

Grade

Third Student Info

First Name

Last Name

Gender

Male

Female

Date of Birth

Grade

Parent Contact Information

Add your contact information

First Name

Last Name

Phone/Mobile

Relationship to Student

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Information

Add an emergency contact information

First Name

Last Name

Phone/Mobile

Emergency Contact Relationship to Student

Emergency Contact Allowed to Pick up/Drop off the Student?

Yes

Pay & Register

Custom Amount

Enter the custom payment amount for all the students you'll be registering. Subject to prior approval.

Pay with Card