Youth Halaqa Registration Form
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Fill in YOUR personal information.
First Name: *
Last Name: *
Cell Phone #: *
Email: *
Spouse First Name: *
Spouse Last Name: *
Spouse Cell Phone #: *
Spouse Email : *
Emergency Contact other than spouse: *
Relationship: *
Phone #: *
Fill in your CHILDREN's information.
1st Child: *
First Name: *
Last Name: *
Child’s Date of Birth: *
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2nd Child:
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First Name:
Last Name:
Child’s Date of Birth:
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DD
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YYYY
3rd Child:
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First Name:
Last Name:
Child’s Date of Birth:
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DD
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YYYY
4th Child:
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First Name:
Last Name:
Child’s Date of Birth:
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DD
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YYYY
5th Child:
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First Name:
Last Name:
Child’s Date of Birth:
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6th Child:
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First Name:
Last Name:
Child’s Date of Birth:
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Liability Disclaimer
o  I hereby release, discharge, and agree to hold harmless New Haven Islamic Center and its officers, volunteers, administrators, and other representative from any and all claims, demands, cost, expenses, and compensation arising out of or in any way related to any injury or other damage caused by me or my children, or anyone included in this form that may result while on premises.

o   Furthermore, I assume all risks incidental to the use of said facilities and shall be solely responsible for any and all accidents and injuries to persons (including death) and/or property damage arising out of or in connection with its activities and use of facilities.

o   I agree to indemnify, defend, and hold NHIC harmless if a claim is brought against NHIC arising out of the group’s use of the NHIC property.
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Sign & Submit Your Form
By signing this application, I agree to abide by the NHIC By-laws and rules. I confirm that the information I have provided is correct.
I understand that by typing my full name below, I am officially signing this application. *
Date: *
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