Registration Form

Registration

PART 1. REGISTRATION FORM:
Kindly fill out all the information and sign the waivers/agreements at the bottom and click the submit button.
Portions with an * are required fields.
Please use a computer to register. Tablets and smart phones often cause trouble during registration.

PART 2. PAYMENT:
Payment options is as noted on the previous page. More information will be sent in your confirmation email upon registering.
***Registration is NOT complete, and child(ren)'s spot will NOT be reserved without payment.***

PART 1: Registration Form

* Indicates required field

Parent 1 *

First

Last

Parent 1 Cell Phone *

Parent 1 Email *

Parent 2 *

First

Last

Parent 2 Cell Phone *

Parent 2 Email *

Child 1 *

First

Last

Gender *

Female Male

DOB (mm/dd/yy) *

Next School Year's Grade Level *

T-Shirt Size *

Please mention any special requests or comments about your child that you would like us to note.

(Quran proficiency, special requests, other comments) *

Child 2 *

First

Last

Gender *

Female Male

DOB (mm/dd/yy) *

Next School Year's Grade Level *

T-Shirt Size *

Please mention any special requests or comments about your child that you would like us to note.

(Quran proficiency, special requests, other comments) *

Child 3 *

First

Last

Gender *

Female Male

DOB (mm/dd/yy) *

Next School Year's Grade Level *

T-Shirt Size *

Please mention any special requests or comments about your child that you would like us to note.

(Quran proficiency, special requests, other comments) *

Child 4 *

First

Last

Gender *

Female Male

DOB (mm/dd/yy) *

Next School Year's Grade Level *

T-Shirt Size *

Please mention any special requests or comments about your child that you would like us to note.

(Quran proficiency, special requests, other comments) *

Are you interested in latchkey *

Yes No Maybe

Latchkey is available from 9 am - 10 am and from 3 pm - 6 pm. Please let us know what hours your child(ren) will need before/after care. *

Home Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Person *

First

Last

Phone Number *

Allergies and/or Special Medical Care

Please indicate any allergies or other medical condition(s) that Noor Summer Camp staff need to be made aware of.
Kindly include your child's name and information below.

**Please Note**
If the box is left empty, staff reserves that right to assume that your child(ren) does/do NOT have any food allergies and/or any health concerns that require special care or attention.

Comment *

Authorization for Pickup

Your child will only be released to an authorized person listed on this form (Parent/guardian and/or emergency contact). In case of an emergency or an unforeseen circumstance, please indicate the full name and phone number of any other person(s) whom you authorize to pick up your child(ren). Child(ren) will not be released to anyone NOT mentioned on this list without verbal/written communication prior. In the case that a parent/gaurdian can not be contacted by contact number provided, child(ren) will not be released.

Person Authorized for Pickup *

First

Last

Transportation Consent

I hereby consent to the above registrant(s) be permitted to participate in Noor Summer Camp field trips, and other activities that will involve the use of bus, vans and/or cars as a form of transportation if applicable. I understand that I will be informed of any field trip via the Email(s) provided on this form.

I consent to the transportation that will be provided by Noor Summer Camp. *

YES

Release of Liability and Authorization for Treatment

I hereby grant permission for my child(ren) to participate in the Noor Summer Camp. Any health concerns or consideration should be acknowledged in writing. In the event I cannot be reached in an emergency, I hereby give my permission to a physician selected by the staff to secure and administer treatment, including hospitalization. I consent to an ambulance being called to transport the child(ren), if necessary, and further understand that I am fully liable for all costs incurred for the transportation. I further agree to hold harmless AIW, NICC and/or Noor Summer Camp, whom are conducting the activities, from any and all claims, suits, losses or related causes of action for damages, including but not limited to such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities.

I release all liability and grant authorization for treatment. *

YES

Photography Consent/Release Agreement

I hereby grant permission to the Noor Summer Camp of Noor Islamic Cultural Center - American Islamic Waqf, to take and use photographs and/or digital images of my child(ren) for use in Noor Summer Camp, NICC-AIW publication and/or presentations. These materials might include but are not limited to printed or electronic publications, website or other electronic communication. I further agree that my child's name and identity may be revealed in descriptive text and/or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negative, prints, digital reproduction shall be the property of the Noor Summer Camp.

Photography Consent/Release Agreement *

YES NO

PART 2: Payment

Payment Agreement

I understand that the fee is $375 per child. Fees include materials, activities, field trip fees, snacks and Friday pizza lunch. Person(s) signing contract are responsible for payment. Payment must be made in person to an NSC staff member on designated payment dates or through optional online payment link that will be provided in confirmation email.

I understand that the registration is NOT complete, and my child(ren)'s spot will NOT be reserved without payment. I understand that my filling out this form is a pledge to pay the total tuition amount, and that a $25 administrative fee is owed for for every withdrawn registration.

Payment Agreement *

YES

Refund/Cancellation Policy Agreement

Refund requests must be made in writing to Noorsummercamp@gmail.com.
Any cancellation made by May 13, 2018 will be granted a 50% refund.
No refunds will granted after the final Deadline, May 13th.
A $25 administrative fee is owed for every withdrawn registration.

Refund Policy Agreement *

YES

Submit Completed Form