About the Program
Past Workshop Sessions
Name of Participant
Age of Participant
Name of Parent/Guardian
Please provide an email address that is checked regularly as we will be providing updates on the camp schedule, program and information sessions available.
Home Phone Number
Health Card Number of Participant
Please Check Off Any Of The Following Health Or Medical Conditions
If you checked off "Other" please specify:
What Was The Date Of Your Child's Last Tetanus Shot (mm/dd/yyyy)?
Please List Anything Your Child May Have A Severe Allergic Reaction To:
Is Your Child Allergic To Any Medication?
Please List Any Medication That Your Child Takes, The Reason, Dosage And Method Of Administration:
Has Your Child Ever Attended An Overnight Camp Before?
TERMS AND CONDITIONS
1.) I give my child permission to attend the Rifqa Retreat program from October 27th - October 29th 2017.
2.) I understand that participation in the activities that make up the Rifqa Retreat is not without some inherent risk or injury. As such, in consideration of my child's participation at the Rifqa Retreat, I hereby release, waive, discharge, and covenant not to sue the Rifqa Retreat program (sponsored by Risalah Foundation), Cedar Glen, their officers, volunteers, agents, or employees from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by myself or my child. Whether caused by negligence of the releasees, or otherwise while participating in such activity, or while in, or upon the premises where the activity is being conducted.
3.) I give my permission for any emergency medical care or treatment to be performed on my child (children) by a physician, surgeon, hospital, or medical care facility that may be required, including transportation, and accept responsibility for the cost. (This would only apply when a serious condition exists and camp staff and medical officials have been unable to contact you, the parent/guardian.)
4.) I hereby give consent for the photograph(s) of my child (children) to/be taken and or released for promotional purposes (in a manner congruent with Islamic practices) by organizers of the Rifqa Retreat.
Signature Of Parent/Guardian
To sign, please type your first and last names in the required boxes.
By checking the box below:
I agree to the terms and conditions listed above