Complete the below form and pay a $25 registration fee to attend our Singles Social Club event on Saturday, October 28, (45-55 yrs) from 6 - 10 p.m. in West Los Angeles. Exact address will be shared upon submission of registration. Spots are limited to 15 men and 15 women per event.

First Name *

Last Name *

Address 1 *

City *

State *

Zip Code *

Phone *

Email Address *

Age *

Gender *

Male

Female

Marital Status *

Single

Married

Legal U.S. Status *

U.S. Citizen

Green Card Holder

Not a Legal Resident

Other Other

What is a fun fact about you? *

Payment Information

There is a required $25.00 registration fee to participate in the Singles Social Club mixer. Please fill out the payment information below for payment processing.

Name on Card *

Expiration Date (mm/yy) *

Credit Card Type *

Credit Card Number *

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Security Code *

Required *

I agree to pay the $25 Singles Social Club registration fee to the Islamic Center of Southern California.

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