Happy Care Children’s Room Registration & Liability Waiver
Anjuman e Shujaee Houston Inc.
Event Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Information
Full Name
*
First Name
Middle Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Child Information
Child's full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the child have any allergies?
*
Yes
No
Please describe the allergies
*
Medical conditions or special needs
Does the child need help using the bathroom?
*
Yes
No
Pick-up & Emergency Contacts
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pick-up Adults
Policy Acknowledgments
I confirm my child is between 2 and 12 years old and toilet-trained
*
Yes
I confirm my child does not have a fever, vomiting, or a contagious illness today
*
Yes
I agree to keep my phone on vibrate and return promptly if contacted
*
Yes
I agree to pick up my child within 15 minutes after the sermon ends
*
Yes
I understand my child will only be released to an adult with the matching numbered tag or an adult listed above and verified by the event lead
*
Yes
I understand volunteers will not give my child any medication
*
Yes
I agree that outside food is not allowed except food provided for my own child, and that room snacks are nut-free
*
Yes
I understand photos and videos of children are not permitted in the room
*
Yes
Release, Waiver and Indemnity
1. VOLUNTARY PROGRAM. I UNDERSTAND THE CHILDREN'S ROOM IS A FREE, VOLUNTEER-RUN SERVICE PROVIDED BY ANJUMAN E SHUJAEE HOUSTON INC. (THE 'MOSQUE') AS A COURTESY DURING THE SERMON. IT IS NOT A LICENSED CHILD-CARE FACILITY.
2. ASSUMPTION OF RISK. I UNDERSTAND THAT PLAY AND GROUP ACTIVITIES INVOLVE RISKS, INCLUDING FALLS, BUMPS, ALLERGIC REACTIONS, ILLNESS, AND INJURY BY OTHER CHILDREN, AND I VOLUNTARILY ASSUME THESE RISKS ON BEHALF OF MYSELF AND MY CHILD.
3. RELEASE. TO THE FULLEST EXTENT PERMITTED BY LAW, I RELEASE AND DISCHARGE ANJUMAN E SHUJAEE HOUSTON INC. AND ALL OF ITS AFFILIATED ENTITIES, INCLUDING WITHOUT LIMITATION DAWAT-E-HADIYAH TEXAS, A CORPORATION SOLE, AND DAWAT-E-HADIYAH AMERICA, A CORPORATION SOLE, AND EACH OF THEIR RESPECTIVE NOMINEES, TRUSTEES, OFFICERS, DIRECTORS, EMPLOYEES, VOLUNTEERS, AND REPRESENTATIVES (COLLECTIVELY, THE 'RELEASED PARTIES') FROM ANY AND ALL CLAIMS, DAMAGES, AND LIABILITY ARISING FROM MY CHILD'S PARTICIPATION, INCLUDING CLAIMS ARISING FROM THE RELEASED PARTIES' OWN NEGLIGENCE.
4. INDEMNITY. I AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS THE RELEASED PARTIES FROM ANY CLAIM BROUGHT BY OR ON BEHALF OF MY CHILD, INCLUDING CLAIMS ARISING FROM THE RELEASED PARTIES' OWN NEGLIGENCE.
5. EXCLUSIONS. THIS RELEASE DOES NOT APPLY TO GROSS NEGLIGENCE OR INTENTIONAL MISCONDUCT.
6. MEDICAL AUTHORIZATION. IF I CANNOT BE REACHED, I AUTHORIZE VOLUNTEERS TO PROVIDE BASIC FIRST AID AND TO CALL 911 AND OBTAIN EMERGENCY MEDICAL TREATMENT FOR MY CHILD, AT MY EXPENSE.
7. GENERAL. THIS AGREEMENT IS GOVERNED BY TEXAS LAW. IF ANY PART IS UNENFORCEABLE, THE REST REMAINS IN EFFECT. I HAVE READ THIS AGREEMENT, UNDERSTAND IT, AND SIGN IT VOLUNTARILY.
I have read and agree to the Release, Waiver and Indemnity above
*
I have read and agree to the Release, Waiver and Indemnity above
Signature
Typed Full Legal Name of Parent/Guardian
*
First Name
Middle Name
Last Name
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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