Al Huda Youth Camp Registration
Please fill out the registration form and make the payment by chase Quickpay at alhudayouthprogram@gmail.com or pay by check.  Payment should be made within three days of the registration to secure the spot for your child.  $130 before June 30th,  thereafter $150.  Upon registration and payment, you will receive a confirmation email and information about the next steps. inshAllah
Sign in to Google to save your progress. Learn more
Camper's Name *
Date of Birth(Must turn 13 by Aug 30th) *
MM
/
DD
/
YYYY
Address, City, State, Zip code *
Email *
Phone Number(Cell) *
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). *
Is your child allergic to any type of food or medication? *
If yes to the above question, please explain.
Emergency Contact Name *
Emergency Contact Phone Number(Cell)
T-shirt size (adult sizes) *
Photo/Video Release: I grant Al-Huda Youth Group permission to use photographic images and/or video recorded during my child’s participation in Youth Camp for promotion, publicity, and/or commercial purposes (website, email, Facebook, print, etc.). I understand that Al-Huda Youth Group may associate my child’s first name with the aforementioned materials, but will not associate my child’s last name without contacting me first. * *
I understand that I will be notified in case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.   I understand that Masjid Al-Huda and Al-Huda Youth and its co-organizers will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *
Waivers & Release: I hereby grant permission for my child to participate in the Al-Huda Youth Camp. I understand that activities involve active games and outdoor activities. I understand that my child’s participation in these activities, as well as those program-related activities not listed, may expose him/her to known danger as well as unanticipated risks. Acknowledging that such risks exist, I hereby waive, release, absolve, indemnify and agree to hold harmless Al-Huda Youth Group, Midwest Islamic Center, Masjid Al-Huda, Al-Huda Academy, Al-Huda Sunday School, respective mentors, coordinators, volunteers, and employees from any and all claims of liability for personal injury or property damage my child may suffer while participating. * *
Name and Signature of the Parent/Guardian *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms