Masjid Assalam (Canadian United Community of Ugandan Muslims)
Program Name: Muslim Youth Circle
Participant Information
First Name
*
Middle Name
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Health Card Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Does the Participant have any medical illness or allergies?
*
Yes
No
If yes, please indicate
Family and Emergency Contact Information
First Contact
Parent/Legal Guardian Name (First, Last)
*
First Name
Last Name
Relationship to Participant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Second Contact
Parent/Legal Guardian Name(First, Last)
First Name
Last Name
Relationship to Participant
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
First Name
*
Last Name
*
Relationship to Participant
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Consent
I authorize Masjid Assalam, (CUCUM), to photograph, record video or audio, and/or interview the participant. I understand that this material may be used for marketing, promotional, or informational purposes by Masjid Assalam, (CUCUM), across various media platforms.
Yes
No
To be completed by parent or legal guardian if participant is under 18 years of age or incapable of giving consent. I have read this form after it was completed, and the information is accurate. I give consent for the participant to take part in the Youth Program
Yes
No
Parent/Legal Guardian Name (First, Last)
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: