Girls Social Event: May 28th, 2022 – WAITLIST – The Academy for Learning Islam

Registration Form
To Be Filled By Parents/Guardians
Child's Name*
First Last
Age*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Number
Cell Phone*
Email Address*
Emergency Contact Details
Name*
First Last
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Number*
Medical Information
Date of Birth*
Date Format: MM slash DD slash YYYY
Health Card Number*
Health Insurance - Name & Number
If you have additional private health insurance, please include this information here. If you do not have any additional health insurance, you may leave this blank.
List any physical or medical limitations that might affect your participation on this retreat*
If you do not have any physical or medical limitations, you may enter "None".
List any allergies that might affect you on this retreat*
If you do not have any allergies that might affect you during this retreat, you may enter "None".
Lunch
Do you have any dietary restrictions?*
- Yes
- No
If yes, please specify:*
Wraps will be provided for lunch.*
- Chicken
- Beef
- Falafel
- None
Indicate wrap choice
Waiver
Agreement*
I have read carefully the registration form and understand this agreement.
Please Note:
1) In the unfortunate instance that you must cancel, we will provide you with refund minus a 50% administration fee. If we do get enough participants then you will be refunded in full.

2) We will be taking pictures which may be used for future events. Please let us know if you would not like your picture taken.

3) The Academy for Learning Islam, its administration, staff and volunteers are not liable for any unforeseen personal injury or loss of any nature that, God forbid, may occur during the event to any of the participants.
Your Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

Girls Social Event: May 28th, 2022 – WAITLIST

Registration Form

Emergency Contact Details

Medical Information

Lunch

Waiver