Evolve Weekend Retreat Form

Evolve Retreat Registration Form
This form must be completed by the parent/legal guardian of the child. Please complete all fields.
Childs Details
Childs Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Address

Full Address

Street Address Line 2

CityState / Province

Post Code
Parent/Guardian Information
Parent/Guardian 1
Name

First NameLast Name
Relationship
E-mail
Phone
Mobile
Parent/Guardian 2
Name

First NameLast Name
Relationship
E-mail
example@example.com
Phone
Mobile
Emergency Information

Parents cannot be listed as an emergency contact. An emergency contact should be able to take responsibility for the child in the event of an emergency or illness in case the parent/guardian cannot be contacted. Any person listed should be over 18 years of age.
Emergency Contact Name

First NameLast Name
Relationship
Contact Number
Medical Information

It is important that you provide us with the correct information about your child's medical health so that we can look after them accordingly
Does your child have any special medical conditions that we should be aware of?

YesNo
If yes, please specify
Is your child taking any medication that we should be aware of?

YesNo
If yes, please specify
Does your child have any food allergies or dietary restrictions that we should be aware of?

YesNo
If yes, please specify
Some activities may be physically demanding (e.g. climbing wall). If you have any concerns regarding your child’s ability to participate fully, please mention them here.
List any additional information about your child that would be useful for staff to know. (Such as behavioural issues, fears, eating or sleeping habits)
Statement of Understanding

The Islamic Foundation we will take all precautions to ensure the safety of participants and to prevent personal injury. Strict guidelines will be issued for participants to ensure their safety and wellbeing while on site. If any incident resulting in personal injury were to occur as a result of your child breaching the rules or guidelines, then that is the responsibility of the child and the Islamic Foundation and its volunteers will not be held responsible.

The Islamic Foundation will take all precautions to prevent the loss or damage of property, however if any of your child’s personal belongings or valuables are damaged or lost, then they are the responsibility of your child and the Islamic Foundation and its volunteers will not be held responsible.

All participants must adhere strictly to the retreat rules and guidelines. If your child causes any problems at the retreat, breaches the rules and guidelines and presents a danger of any sort then the Islamic Foundation reserves the right to send them home early without a refund.
Statement of Understanding*

I Accept
The participation agreement below must be read and signed by your child.

I agree to adhere to all the safety rules and guidelines issued at the retreat. I agree to follow the Islamic rules and etiquettes around gender mixing. I agree to participate to the best of my ability in all scheduled activities and to act respectfully and considerately toward fellow participants, staff, speakers and mentors. I will be respectful towards the venue and take responsibility for cleaning up after myself. I understand the responsibility of keeping my belongings safe and that any valuables and personal items I bring are my own responsibility. I agree to stay within the spaces provided and not leave the premises during the duration of the retreat. I understand that leaving the site without adult supervision is strictly prohibited and my doing so will result in immediate expulsion from the retreat.
Participation Agreement

I Accept
Child Name

First NameLast Name
Date

MonthDayYear
Date
Child Signature*

Clear
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Photos and videos will be taken at the retreat for promotional use by the Islamic Foundation in future. I, the parent/guardian of the child named above, give my consent for photos and videos in which my child may be included.

YesNo
This form was completed by Parent/Guardian

First NameLast Name
Date

MonthDayYear
Date
Signature*

Clear
Payment
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Evolve: Weekend Retreat£60.00

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Evolve Retreat Registration Form

Childs Details

Parent/Guardian Information

Emergency Information

Medical Information

Payment