2026 MGN Registration

Select MGN Location
Student Information
Student Full Name*
Student Phone Number*
Please enter a valid phone number.
Student Email (non-school email if possible)*
example@example.com
Date of Birth*

MonthDayYear
Date
Age*
Ethnicity*
Gender*
Education Level
If you exited highschool early, please select the grade you would have been in now.
Shirt Size
List Any Allergiess*
ex. peanut butter, can't consume or smell it
Parent/Guardian/Emergency Contact
Guardian Full Name*
Guardian Phone Number*
Please enter a valid phone number.
Relation to Student*
Guardian Email*
Would you be open to receiving emails from us?

Yes, let's stay in touch!No, Thank You.
Program

Students will fill this out.
Please specify the mosque or institution where you will be attending MGN.*
List any clubs, sports, or extracurricular activities that you are involved in.*
How often do you frequent the mosque?*
If you attend a mosque, list the mosque name(s).*
How did you hear about the program?*

My Local MosqueCAIR-LA NewsletterCAIR-LA Social Media PlatformCAIR-LA Community Whatsapp GroupOther

Media Release Form

Muslim Gamechangers Network
This form grants permission to the CAIR-CA to use your likeness and information for purposes related to the MGN.

Please review carefully before signing.
By signing below, you grant CAIR-CA the right to:
- Use your full name, personal information, biography, and photo/video image.
- Use your likeness (including pictures, photographs, silhouettes, etc.) in various media formats.
- Distribute, advertise, promote, exhibit, and exploit your likeness worldwide, in perpetuity, and on any media format (existing or future).
  You also agree to:
- Not to sue CAIR-CA for using your likeness as authorized in this form. This includes claims based on invasion of privacy or publicity rights.
- Release CAIR-CA, its directors, officers, and associates from any liability related to the use of your likeness as authorized in this form.
Please note:
- This permission is granted for the Muslim Gamechangers Networking Program.
Choose one of the following:

I consent to the use of my name, photograph, video, or audio recordings in various media formats, including but not limited to publications, websites, social media, and promotional materials.I do not consent to the use of my name, photograph, video, or audio recordings in any media formats.

Registration Fee*

Student Registration Fee

$25.00 Student Quantity
Item subtotal:$0.00

Enter coupon

Total

$0.00

Student Information