ARISE Registration Fall 2020

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A Project of The Multi Cultural Center - EQRA

PARTICIPANT INFORMATION

First and Last Name *

Date of Birth *

Grade Level

School Name

Address *

Participant Primary Phone Number

Participant Email address

What do you, the participant, hope to achieve by participating in the ARISE program?

I plan to attend: *

all sessions

selected sessions

Please select which sessions you plan to attend *

all sessions

self esteem

mood management

goal setting

decision making

disciplinary skills

relationship management (anger management and conflict resolution)

social tolerance

communication skills

cooperation

bullying

attitudes towards drugs

Required

PARENT / GUARDIAN INFORMATION

Parent First and Last Name

Parent Primary Phone Number

Parent Secondary Phone Number

Parent Email address

PARTICIPANTS UNDER 18 MUST HAVE PARENT OR LEGAL GUARDIAN SIGN BELOW:

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by MAS-MCC-EQRA-ARISE during the selected time period. In exchange for the acceptance of my child’s candidacy by the ARISE Program, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Muslim American Society and its volunteers, facilitators and representatives from any and all liability for injuries to said child arising out of participating in program sessions. ***Due to the fully online virtual nature of this year's program (2020-2021) there are no predicted risks.

I have read and agree to informed consent

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