Summer Camp 2018 | Darul-imaan Institute

Summer Camp Registration Form

Student Information
Please Provide Student information.
Number of Children*
- One
- Two
- Three
You can apply for up to three children using this one Application form. if number of children are greater than 3, please fill out for the remaining children in separate Application form.
1st Child's Name*
FirstLast
Date of Birth*
Gender*
- Male
- Female
Health Card no*

Alternative Emergency Contacts
Please Provide Alternative Primary Emergency Contact information.
Primary Emergency Contact
Home Phone
Work Phone
Address
City, ST ZIP Code

Alternative Emergency Contacts
Please Provide Alternative Secondary Emergency Contact information.
Secondary Emergency Contact
Home Phone
Work Phone
Address
City, ST ZIP Code

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.
Parent’s/Guardian’s Signature*
Date*
I give permission for my child to go on field trips (if any). I release Darulimaan Institute and individuals from liability in case of accident during activities related to Summer Camp, as long as normal safety procedures have been taken..
Parent’s/Guardian’s Signature*
Date*
Email
This field is for validation purposes and should be left unchanged.

Student Information