Form Test PageICCP Sunday School / Friday Quran Classes / Tuesday Adult Tajweed class Registration for the Year: 2023-2024SUNDAY SCHOOL FORM"*" indicates required fieldsChoose The Stream*Please choose an optionSunday SchoolFriday Quran SchoolFull name of first Participant*Date Of Birth* DD slash MM slash YYYY Full name of second ParticipantDate Of Birth DD slash MM slash YYYY Full name of third ParticipantDate Of Birth DD slash MM slash YYYY Other with DOB*Name of Parents with phone numbers*Email* Home Address*Please mention if your Participants have any Allergy element**Please mention the status of vaccines of your Participant**Waiver FormPARENT/ GUARDIAN INFORMATION*Full name*Email address of parent/ guardian* CONTACT DETAILS*Full name*Phone*Full namePhoneEMERGENCY CONTACT*Full name*Relation*Full nameRelationChild's name (Participant)*Acceptance* I, am the legal guardian of ___ (child’s name (“Participant”), and grant permission of (child’s name (“Participant”), and grant permission to him / her to attend and participate fully in YOUTH CIRCLE , ICCP Sunday School / ICCP Quran Class / ICCP Events / Retreats during the year 2023 To 2024Acceptance* OVER-THE-COUNTER MEDICATION PERMISSION: Do you give permission for your child/youth to be given over- the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at an ICCP event?Acceptance* No. Contact me or get medical help if my child has any minor medical concerns.Acceptance* Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.Name of Parent/Guardian*Guardian Date* DD slash MM slash YYYY Acceptance* LIABILITY RELEASE: In consideration of ICCP allowing the Participant to participate in these ICCP children/youth programs, I, the undersigned, do hereby release, forever discharge and agree to hold harmless ICCP, its administrators, directors, employees, volunteers and teachers (collectively herein the “ICCP”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death or damage as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify ICCP for any liability sustained by ICCP as the result of the negligent, willful or intentional acts of the Participant, including financial loses. Initials:Acceptance* MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. Initials:Acceptance* PHOTO RELEASE: I grant permission to ICCP to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the activities at ICCP. Initials:Select the amount to pay $350 $400 $700Fall Semester: 350 dollars first kid with 10 percent sibling discount (Including Books) Spring Semester: 400 dollars first kid with 10 percent sibling discount Full Year: 750 dollars first kid with 10 percent sibling discountPayment MethodPayPal CheckoutMasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
