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Kalimah Programs Registration Form
1
Participant's Name
*
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First Name
Middle Name
Last Name
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2
Parent/Guardian's Name (if participant is a minor)
First Name
Middle Name
Last Name
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3
Second Parent/Guardian's Name (if participant is a minor)
First Name
Middle Name
Last Name
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4
Participant's Date of Birth
*
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Month
Day
Year
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5
Gender
*
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Please Select
Male
Female
N/A
Please Select
Please Select
Male
Female
N/A
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6
Participant's Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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7
Participant's E-mail (if participant is a minor, a parent's e-mail address is required)
*
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8
If participant is a minor, enter a second parent or guardian's e-mail address
example@example.com
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9
Phone Number (if participant is a minor, a parent's phone number is required)
*
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Area Code
Phone Number
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10
If participant is a minor, enter a second parent or guardian's phone number
Area Code
Phone Number
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11
Program(s) of Interest
*
This field is required.
This is just to know what programs to offer in the future. Select all options you would be interested in.
After School Program
Arabic Calligraphy
Art Workshop
Family Yoga
Kids Play Group
Mommy and Me Group
Movie/Game Night
Weekend Arabic Immersion
World Arabic Language Day
Youth Workshop
Other
Please Select
After School Program
Arabic Calligraphy
Art Workshop
Family Yoga
Kids Play Group
Mommy and Me Group
Movie/Game Night
Weekend Arabic Immersion
World Arabic Language Day
Youth Workshop
Other
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12
Allergies, Special Needs, and/or Accommodation Requests
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13
Questions/Comments
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14
Waiver and Consent
*
This field is required.
By submitting this form, I, the participant or parent/guardian of the named child above, agree to the following terms: (1) I give consent to and allow Kalimah Programs to use pictures, audio, video, and other recordings and images of me/my child during Kalimah Programs in promotional materials, news, updates, and others, printed and digital; (2) payment of program tuition and fees as advertised must be received by Kalimah Programs at least 20 days before the start date of the program (https://squareup.com/store/kalimah/), delay in remitting payment may result in cancellation of this registration and the spot becomes available to other registrants; (3) no refund will be issued if cancellation is requested less than 10 days prior to the start date of the program; (4) classes/meetings/workshops may be cancelled or rescheduled due to inclement weather or other reasons at the discretion of the program director; every effort will be made to give ample notice to participants/parents and to reschedule cancelled times within 30 days of the advertised end date of the program; (5) I consent to and give my child permission to participate in all Kalimah Programs' activities; Kalimah is not responsible for any harm or injury that may result from my or my child's participation in named program or any activities under supervision of any Kalimah personnel, affiliates, or volunteers; I release, hold harmless, and indemnify Kalimah Programs and all of its staff, contractors, volunteers, and affiliates from and for any claim, injury, or other liability of any kind which is caused directly or indirectly by participant or which results from or during my/my child's participation in the program; I consent to emergency treatment when needed for me/my child. (Please sign with your full name and date)
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15
Payment (Please choose at least one and change its quantity to 1 in the quantity box to see its fee)
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ORDER SUMMARY
Total cost
USD
Calligraphy Workshop (per participant)
$
20.00
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List names and ages of all participating members here.
Without personal calligraphy kit
With personal calligraphy kit
Calligraphy kit only
Without personal calligraphy kit
Without personal calligraphy kit
With personal calligraphy kit
Calligraphy kit only
Optional: Personal Calligraphy Kit to take home (hand-cut pen, ink, inkwell, and paper)
World Arabic Language Day: Entry Ticket (pre-registration is required; seating is not guaranteed on the day of event without this registration; calligraphy workshop registration is a separate item on this form; some optional activities may require cash payment directly to vendors)
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