Family Application
Name *
Your answer
Age *
Your answer
DOB *
MM
/
DD
/
YYYY
House No. *
Your answer
Address Line 1 *
Your answer
Address Line 2
Your answer
City *
Your answer
Postal Code *
Your answer
Mobile *
Your answer
Home Telephone
Your answer
Email *
Your answer
Occupation (state previous one if currently unemployed) *
Your answer
University attended (if relevant) and qualification obtained *
Your answer
Please state whether you have attended any weekend seminars or retreats previously, giving details of titles, topics, teachers and approximate year attended *
Your answer
Please state details of any regular Islamic class you attend giving details as above *
Your answer
Are you involved in any community activities or programmes at present? *
Your answer
Do you take any non-Islamic classes, present or previous? *
Your answer
Do you attend a local Masjid regularly, and if so, which one(s)? *
Your answer
Where did you hear about this Retreat, and what was the main reason of applying *
Your answer
What are your expectations from such a program organised by PG *
Your answer
If you need financial help please state the amount needed and a brief statement on your personal circumstances which necessitate financial aid. All details provided will be kept strictly confidential *
Your answer
If you would prefer to spread payments using a payment plan then please indicate here *
No Payment Plan
Payment Plan Required
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Under 18 - Child 1
Child 1: Name *
Your answer
Child 1: Age *
Your answer
Under 18 - Child 2
Child 2: Name
Your answer
Child 2: Age
Your answer
Under 18 - Child 3
Child 3: Name
Your answer
Child 3: Age
Your answer
Under 18 - Child 4
Child 4: Name
Your answer
Child 4: Age
Your answer
By submitting your application you agree to the following:
The personal details submitted in this form will be kept private and not shared or seen by anyone other than the PG shura, and then kept on record securely in case future correspondence is necessary. *
Required
Anyone under the age of 18 must be accompanied by their father/male guardian. Photo ID for age verification of 18 year olds and over may be requested. Ages 9 and under are not allowed *
Required
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