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First & Last Name *
DOB *
MM
/
DD
/
YYYY
Address  *
Contact Number *
E-Mail ID *
Emergency contact person  *
Relationship to contact  *
Emergency contact number *
Are you affiliated or associated with any organization?  *
If yes, what is the name of the organization? Write N/A if your answer is no.  *
By printing my full name below I hereby release and waive and agree to hold harmless and indemnify Attawheed Islamic Center (AIC), its members, directors, officers, agents, employees, contractors, teachers, staff and volunteers, and its affiliates, successors and assigns, from all claims, costs, assessments, losses, litigation costs (including reasonable attorney and other professional expenses), and damages arising for any reason whatsoever during my stay in the masjid. I further hereby consent and agree to be bound by all applicable AIC rules, regulations, bylaws, terms and provisions and will NOT perform any activities that are against the AIC bylaws.
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