2018 Ramadan Qiyam Signup
Dates for Qiyams Ramadan 2018:

Middle School Girls Qiyam - Friday May 25, 2018
Middle School Boys Qiyam - Saturday May 26, 2018

High School Girls Qiyam - Friday June 1, 2018
High School Boys Qiyam - Saturday June 2, 2018

Youth's First Name *
Your answer
Youth's Last Name *
Your answer
Gender *
Date of Birth
MM
/
DD
/
YYYY
Current Grade Level *
Parent Guardian #1 Full Name *
Your answer
Parent Guardian #1 Email Address *
Your answer
Parent Guardian #1 Phone Number *
Your answer
Parent Guardian #2 Full Name
Your answer
Parent Guardian #2 Email Address
Your answer
Parent Guardian #2 Phone Number
Your answer
I will be able to drop my youth off at NICC at 12am, sign them in, and understand that volunteers will not take responsibility of overseeing my son/daughter until that time. *
I agree to pick my child up from the Noor Islamic Cultural Center promptly following Fajr Salah or make other arrangements for their transportation. I understand that failure to do so may result in the disqualification of my son/daughter from future Qiyams. *
I agree to the payment of $10 for the Qiyam registration fee and will bring the payment with my child to the Qiyam. *
I understand that in the case of disciplinary action my son/daughter may be asked to sit out or even be disqualified from future events on account of their bad behavior? *
I have saved Br. Shafiq Luden's phone number (614-905-6494) and Sr. Amina Barhumi's number (248-635-1843) in case alternate transportation arrangement must for made for may son/daughter. *
I understand and will communicate with my child that s/he needs to act responsibly, listen to chaperones and event volunteers and carry themselves respectfully. Failure to do so will result in participant's disqualification from future events. *
Noor Islamic Cultural Center NICC Youth Committee Qiyam Liability Release In consideration of the furtherance of your purposes, objectives and aims, and in consideration of you permitting me to participate in your NICC Youth Committee Qiyam, on behalf of myself, my heirs, executors, administrators and assigns, I hereby waive and release any and all rights and claims for damages which I may have against you, Noor Islamic Cultural Center, as well as any other person, sponsors, organization or corporation, their heirs, executors, administrators, and assigns who are providing services or assistance as a result thereof. Authorization For Treatment I hereby grant permission for my child(ren) to participate in the NICC Youth Committee Qiyam. Any health concerns or consideration should be acknowledged in writing along with the release form. In the event I cannot be reached in an emergency, I hereby give my permission to a physician selected by the staff to secure and administer treatment, including hospitalization. I consent to an ambulance being called to transport the child(ren), if necessary, and further understand that I am fully liable for all costs incurred for the transportation. I further agree to hold harmless NICC and/or the NICC Youth Committee Qiyam Program Staff, whom are conducting the activities, from any and all claims, suits, losses or related causes of action for damages, including but not limited to such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities. Transportation Consent I hereby consent to the above registrant(s) be permitted to participate in NICC Youth Committee Qiyam, and other activities that might involve the use of bus, vans and/or cars as a form of transportation if applicable. Do you, as a legal parent or guardian, give consent, in recognition of these terms, allow your child to attend this program? If so please type your name as the parent or legal guardian below. *
Your answer
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