Risalah Foundation
PLEASE COMPLETE FORM AND SUBMIT TO REGISTER FOR RUJULAH 2019
Parent/Guardian Information:
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Indicates required field
Parent Name (First & Last)
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Phone Number:
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Parent / Guardian Email
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Emergency Number:
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Participant Information:
Participant 1 Name (First & Last)
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Age:
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PLEASE LIST ANY ALLERGIES, MEDICATIONS AND ANY MEDICAL CONDITIONS PARTICIPANT 1 HAS:
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Participant 2 Name (First & Last)
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Age:
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PLEASE LIST ANY ALLERGIES, MEDICATIONS AND ANY MEDICAL CONDITIONS PARTICIPANT 2 HAS:
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Participant 3 Name (First & Last)
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Age:
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PLEASE LIST ANY ALLERGIES, MEDICATIONS AND ANY MEDICAL CONDITIONS PARTICIPANT 3 HAS:
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Comments:
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Payment Information:
FEE:
$275* (Non-refundable)
Due by Oct 9th, 2019
Payment Options
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In-Person
Online
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Method of Payment
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Cheque
Debit/Credit Machine (on-site)
Online (www.donorbox.org/rujulah)
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Waiver:
Terms & Conditions:
1. I give my child(ren) permission to attend the Rujulah Retreat program from October 12th to October 14th 2019.
2. I understand that participation in the activities that make up the
Rujulah
Retreat is not without some inherent risk or injury. As such, in consideration of my child(ren)'s participation at the
Rujulah
Retreat, I hereby release, waive, discharge, and covenant not to sue Risalah Foundation, its staff, organizers,
Rujulah
Retreat volunteers, organizers, participants, Mansfield Centre, their officers, volunteers, agents, or employees from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by myself or my child. Whether caused by negligence of the releasees, or otherwise while participating in such activity, or while in, or upon the premises where the activity is being conducted.
3. I give my permission for any emergency medical care or treatment to be performed on my child(ren) by a physician, surgeon, hospital, or medical care facility that may be required, including transportation, and accept responsibility for the cost. (This would only apply when a serious condition exists and camp staff and medical officials have been unable to contact you, the parent/guardian.)
4. I hereby give consent for the photograph(s) of my child (children) to/be taken and or released for promotional purposes (in a manner congruent with Islamic values) by organizers of
Rujulah
Retreat.
Parent Name (First & Last)
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BY CHECKING THE BOX BELOW:
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I agree to the terms and conditions listed above
Submit