2017 NASIMCO Youth Leadership Retreat: Registration Form
Making Your Voice Count: Thinking Outside The Box

The NASIMCO Youth Leadership retreat is an annual program organized to empower youth to explore and develop leadership opportunities. The retreat combines facilitated workshops, debates, dialogue and recreational activities in order to optimize learning opportunities for all participants. The retreat will be held during Labor Day weekend, from September 1st to September 4th, 2017 at the Sanctum Retreat Center located outside of Edmonton, Alberta. The goals of the retreat are as follows:

• To enable participants to explore assumptions, beliefs and attitudes about themselves, and the environments in which they operate

• To develop the capacity for social and political leadership among the youth

• To facilitate the spiritual and social upliftment of youth in North America

• To enable the youth to realize their full potential

2017 Retreat Information
When: Fri. Sept. 1st (Afternoon) - Mon. Sept 4th (Afternoon)
(Labor Day Long Weekend)

Who: Ages 18 to 25

Where: Sanctum Retreat Centre, Edmonton, Alberta

Cost: $275 CAD per person (sponsorship can be requested from your respective Jamaats/Communities)

Transportation: Bus service to & from the Islamic Shia Ithna-Asheri Centre of Edmonton, Alberta to the Retreat Center will be provided at no extra cost.

**Space is limited. Deadline to register is July 31st, 2017**

Note: Applicants are asked not to book their flights until your spot at the retreat is confirmed. Applicants who do not receive a spot or need to cancel, refunds are available until August 15th, 2017. Exceptions are made for emergencies. If there are any questions please contact us at retreat@nasimco.org. Thank-you!

Registration Form
Name *
Your answer
Sex *
Age *
Your answer
Email *
Your answer
Address *
Your answer
Occupation *
Your answer
Phone Number *
Your answer
What community do you affiliate with or belong too? *
Your answer
T-shirt Size *
Receive a complimentary retreat t-shirt. Please indicate your preferred sizing and sleeve length. If you require any size not indicated, please mention in "other" and we will do our best to accommodate you.
Emergency Contact Name *
Your answer
Relationship to you: *
Your answer
Emergency Number *
Your answer
Dietary Requirements
Disability Accommodations:
The NASIMCO Retreat Team actively encourages applications from youth with disabilities.

Should you require an accommodation in order to participate in this retreat, please email us at retreat@nasimco.org

Additional Information
In 250 words or less, please complete the following questions in support of your application:
What are you passionate about? *
Your answer
What activities, initiatives or programs are you currently involved in outside of work or school? If you are not involved, then what would you like to be involved in? *
Your answer
What does “Thinking outside the Box” mean to you? *
Your answer
Why are you applying to attend the 2017 Retreat? What do you expect to get out of the 2017 Retreat? *
Your answer
In your view, what are the current issues, needs, pressures or roadblocks facing the youth of your community? *
Your answer
Do you feel the youth have a voice or are actively involved in your community? If yes, please provide examples of the programs or events they are involved in. If no, why do you think they are not involved? *
Your answer
What possible community needs or problems, challenges, or issues can you identify that you care about? *
Your answer
At the end of this retreat, will you make time to apply your knowledge and work on projects that will benefit your community? If yes, please explain how you would plan to *
Your answer
I take full responsibility in participating in the activities made available at this camp.

Permission is granted for me to receive emergency medical treatment if needed the cost of which will be paid by me. I hereby release and discharge NASIMCO, its officers, all its affiliated entities, volunteers, organizers, chaperones and representatives from any and all liability, claims, demands, damages, costs, expenses, personal injuries, and/or loss suffered by me in connection with my participation in the camp.

I agree that the grant and release contained therein binds me to all of its terms.

I understand and agree to the waiver outlined above.

Participant Name: *
Your answer
Date: *
Your answer
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