AMIC - I’tikaf Registration Form
This form is intended to collect information from individuals interested in participating in I’tikaf during Ramadan. By filling out this form you will help us ensure a meaningful and well-organized experience for all participants.
1) Name
*
First Name
Last Name
2) Age (individuals under 18 years old must be accompanied by a parent/guardian on the premises overnight)
*
3) Gender
*
Please Select
Male
Female
N/A
4) Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5) Contact Email Address
*
example@example.com
6) Contact Mobile Number
*
Please enter a valid phone number.
7) Emergency Contact - Full Name
*
8) Emergency Contact - Mobile Number
*
9) Any other relevant information, e.g. allergies or medical conditions we should know about? Please use this space to list any medications you are on.
*
10) Preferred dates for I’tikaf
*
11) Duration of I’tikaf
*
Would you like to join our email broadcast list? We won't share your details and you can unsubscribe anytime if you like.
*
YES
NO
Submit
Should be Empty: