Summer Camp 2022 | Darul-imaan Institute

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*
Allergies/Special Health Considerations/ Any Behavioural Pattern we need to know

Student Information
Please Provide 2nd Student information.
2nd Child's Name*
FirstLast
Date of Birth*
Gender*
- Male
- Female
Health Card no*
Allergies/Special Health Considerations/ Any Behavioural Pattern we need to know

Student Information
Please Provide 3rd Student information.
3rd Child's Name*
FirstLast
Date of Birth*
Gender*
- Male
- Female
Health Card no*
Allergies/Special Health Considerations/ Any Behavioural Pattern we need to know

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

Any expectations you have from Dar Ul Imaan for this Summer Camp
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 release Darulimaan Institute and individuals from liability in case of accident during activities related to Workshop, as long as normal safety procedures have been taken..
Parent’s/Guardian’s Signature*
Date*
Name
This field is for validation purposes and should be left unchanged.

Student Information