Parent Information
Mother's Name
*
First Name
Last Name
Father's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
(000) 000-0000
Email
*
example@example.com
Youth Information
Program(s) Interested In
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( X )
Fajr Club Gear
$40.00
$
40.00
T-Shirt
XS
S
M
L
XL
XXL
XXXL
Sports
$120.00
$
120.00
GBIC FC
Number of Youths
1
2
3
4
5
6
7
8
9
10
Quran & Arabic
$100.00
$
100.00
Number of Youths
1
2
3
4
5
6
7
8
9
10
Jummah Night Lights
Free
$
Free
Number of Youths
1
2
3
4
5
6
7
8
9
10
Boys & Dads Club
Free
$
Free
Number of Youths
1
2
3
4
5
6
7
8
9
10
Kids Club
Free
$
Free
Number of Youths
1
2
3
4
5
6
7
8
9
10
Fajr Club
Free
$
Free
Number of Youths
1
2
3
4
5
6
7
8
9
10
Total
$0.00
$
0.00
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Youth Names & Birth Dates
*
Known Allergies or Other Pertinent Information (if any)
Emergency Contact Information
Contact Name
*
First Name
Last Name
Contact Phone Number
*
(000) 000-0000
E-Signature
I hereby acknowledge that I intend to participate in activities with the aforementioned groups that will take place on the Grand Blanc Islamic Center (GBIC) Campus (1479 E Baldwin Rd, Grand Blanc, MI 48439) or in case of planned field trips within the 10-15 mile radius. I am aware that these activities have risks of loss, physical injury and even death and I am voluntarily participating in these activities with knowledge of those risks. I hereby release and discharge GBIC, its directors, officers, members, agents representative, employees, instructors, volunteers, successors and assignees from any claim I now have or may hereafter have resulting from my use of the GBIC facilities and equipment. To the fullest extent permitted by law, I agree to defend, indemnify and hold harmless GBIC, its directors, officers, members, agents, representative, employees, instructors, volunteers, successors and assignees, for and against any and all claims, demands, actions, losses and expenses of every kind in any way arising out of my activities under this release. I further acknowledge there are no warranties, express or implied, concerning the facilities, equipment or activities at GBIC. Furthermore, in case of injury, if I cannot be reached within a reasonable time, I authorize GBIC, and/or its agents or volunteers to obtain necessary medical treatment for my child (if under 18). I also assume the financial responsibility for any medical treatment for my child. Grand Blanc Islamic Center, as part of its programming, frequently photographs and video tapes those who participate in various sponsored events. These photos and videos are used for historic documentation as well as for publicity purposes. By my signature, I give permission and full consent for my youth to be photographed or videotaped as part of GBIC-sponsored or associated events and understand that photos or video of the event may be used in one or more promotional pieces, displayed throughout the building and/or on the GBIC web site. This permission may be revoked in writing and submitted to the Youth Director, GBIC Administrator or Imam. By my signature, I give consent for GBIC to reach out to me and the phone numbers provided as a means of communication at anytime.
*
Participant Signature (or parent, if under age 18) PRINTED
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