2023 IAR Youth Programs Registration Form

Alsalaamu 'alaikum wa rahmatu Allaahi wa barakaatuhuu

This is the master registration form for the Islamic Association of Raleigh's (IAR) Youth Committee Programs (all ages). It is important that you fill out this form for your child to be able to participate in the programs and activities. There is an ANNUAL $20 registration fee, per participant, without which this form's status will be "incomplete."

Before filling out this form, please check if the participant's information has already been submitted through this form:

https://tinyurl.com/iar-youth-23-check

Ahsana Allaahu ilaikum wa jazaakumu Allaahu khairan.



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Email *
Participant Information
Please enter all information as completely as possible.
Sex *
Participant's Full Name *
Please enter the participant's full name, including any hyphens or other important characters.
Is the participant fully* vaccinated and boosted against COVID-19? *
This information allows us to more effectively plan for the wellbeing of our youth, bi ithni Allaah.
Participant's D.O.B. *
Please enter the participant's date of birth [format:  MM / DD / YYYY].
Participant's Age *
Please enter the participant's age as of January 1, 2023
Participant's Phone Number [Format:  (123) 456-7890]
[OPTIONAL] Please enter the participant's phone number.
Participant's E-mail Address
[OPTIONAL] Please enter the participant's e-mail address.
Participant's Address Line 1 *
Please enter the participant's home address street number and name.
Participant's Address Line 2
Apt. #, etc.
Participant's Address City *
Please enter the participant's home city.
Participant's Address State *
Participant's Address Zipcode *
Participant's Preferred Communication Means
[OPTIONAL] Please select how we may communicate with the participant. [Check all that apply.]
Participant's School *
Enter the participant's current school (type "home school" for home-schooled participants).
Participant's Grade Level *
Please enter the participant's grade level for the 2022-2023 school year.
Participant's Program Status *
Is the partipant a New or Current (or Past) member of the programs?
Participant's Medical (Insurance) Information

[OPTIONAL] Please provide the medical information to be viewed and used by the programs' organizers ONLY as necessary.
Participant's Doctor's Name
Participant's Doctor's Phone Number
Participant's Insurance Company
Participant's Insurance Company Phone Number
Participant's Insurance Policy Number
Participant's Insurance Group Number
Participant's Allergies / Medications / Conditions *
List any allergies / medications (e.g., food allergies, penicillin, poison ivy, drug allergy, serum sensitivity, EpiPen, penicillin, etc.), medical situations (e.g., diabetes, asthma, etc.), and/or medications that the programs' organizers should be aware of to help facilitate an all-around amazing experience for your child.  [If none, please enter, "Bi hamdi Allaah, none."]
Participant's Injuries / Disabilities *
Does the participant have any past and/or current injuries or disabilities (e.g., physical conditions, alternative mobility, bone injuries, etc.) that would prevent your child from participating in certain activities?  Please list and detail.  [If none, please enter, "Bi hamdi Allaah, none."]
Any Additional Information *
Recent illness or operation?  Under the care of a doctor?  Please enter anything else (NOT already mentioned) that you, as a parent / guardian, would like for the program organizers to know that would help all parties involved in planning and carrying out programs.  [If none, please enter, "Bi hamdi Allaah, none."]
Parent / Legal Guardian Information
Please enter the information for the parent / LEGAL guardian who we may contact for any necessary communications (e.g., including advertisement, emergencies, questions, etc.).
Parent's / Guardian's Full Name *
Please enter the parent's / guardian's full nume.
Parent's / Guardian's Phone Number [Format:  (123) 456-7890] *
Please enter the phone number with which we may contact the parent / guardian in case communication is necessary.
Parent's / Guardian's E-mail Address
[OPTIONAL] Enter if this is different from the e-mail address at the very beginning.
Parent's / Guardian's Preferred Communication Means *
Please enter the means of communication we may use to contact the parent / guardian.  [Check all that apply.]
Required
Custody-Related Information
NOTE: If you have a custody arrangement with your child's other parent, please fill-out this section with the details for the other parent.

This helps us in emergency or other atypical situations.

If this is not relevant to you, please skip to the Emergency Contact Person section.
Second Parent's Full Name
Second Parent's Phone Number
Second Parent's E-mail Address
Fill this out in case the other parent would also like to receive information about your child's programs and activities.
Second Parent's Address Line 1
Second Parent's Address Line 2
Apt. #, etc.
Second Parent's Address City
Second Parent's Address State
Second Parent's Address Zipcode
Second Parent's Preferred Communication Means
Please enter the means of communication we may use to contact the second parent. [Check all that apply.]
(Back-Up) Emergency Contact Person
Please provide the details for a back-up emergency contact person in case YOU, the parent / legal guardian listed above, are NOT reachable, or as we see necessary.
Emergency Contact's Full Name *
Please enter the emergency contact's full name.
Emergency Contact Relationship to Participant *
How is the emergency contact person related to the participant (e.g., paternal uncle, brother, another parent, maternal aunt, cousin, etc.)?
Emergency Contact's Phone Number [Format:  (123) 456-7890] *
Please enter the phone number with which we may contact the emergency contact person in case of emergencies or as necessary.
Waiver
I hereby give full permission for my child to participate in the Islamic Association of Raleigh (heretoforth referred to as "IAR") Youth Committee's 2023 Programs and Activities.  I understand that the well-being and safety of my child are of utmost importance to the IAR's Youth Committee's Programs' organizers, and I, as the listed parent / legal guardian, hereby release the IAR and any associated youth program organizers and volunteers of any and all liabilities and assume full responsibility in case of any accident or injury before, during, and after the IAR's Youth Committee's 2023 Programs and Activities.

I grant IAR's Youth Committee organizers, staff, and staff-designated volunteers, as associated with the Islamic Association of Raleigh, full authority to use their judgment in obtaining and providing emergency medical care deemed necessary to protect the health and safety of the above named participant (attendee), a member of my family, at my expense.  This care may include, but is not limited to, placing him/her under care of a doctor or a hospital.  I hereby release, hold harmless, and indemnify IAR and its organizers or agents, either in their individual capacities or by reason of their relationship with the IAR, from all responsibility, liability, or claims of any nature whatsoever for loss, damage, or destruction of property, or injury due to any cause whatsoever to my family members attending any of the IAR's Youth Committee's Programs and Activities.

I, the undersigned parent / legal guardian of the participant named above, hereby understand the inherent risks of the programs and activities, and I do, hereby, absolve the IAR, all of its employees and volunteers, and all of its constituents and associates from any and all liability, actions, causes of action, claims, and demands of every kind and nature whatsoever which I now have or which may arise out of or in connection with my child, named above, participating in any of the IAR's Youth Committee's Programs and Activities.  I understand that the IAR and the organizers of the IAR's Youth Committee Program and Activities will be doing their best to mind the safety and security of the participants as a top priority, inn shaa’a Allaah.  I understand that after doing my part, putting my trust in Allaah, Al-Haafith (The Guardian), is a suggested next step.

I acknowledge that this waiver and its terms are valid at least until I fill out the form for IAR's Youth Committee's 2023 Programs and Activities.
I have read and agree to the conditions of the waiver, and accept the waiver conditions. *
Waiving Parent's / Guardian's Full Name *
Please enter the full name of the parent / legal guardian who hereby agrees to the waiver details above.
Date *
Please enter today's date, or the date on which the conditions of the above waiver were accepted (format:  MM / DD / YYYY).
Photo Release
I, the under-named, parent / legal guardian of the above listed participant, hereby give my permission to the Islamic Association of Raleigh (IAR), their releases, and to their designated photographer(s) [i.e., counselors, program organizers, etc.], my free and unlimited consent to publish/broadcast, republish/rebroadcast or exhibit in the furtherance of their work, with or without the identification of me or my child by name, any photographs, videos, or audios of myself or my child, that have been obtained from my or my child's participation in any of the IAR's Youth Committee's 2023 Programs and Activities.  I furthermore waive any and all claims for any compensation by reason thereof or for damages for reasons thereof.
I have read and agree to the conditions of the photo release above, and accept them. *
Date *
Please enter today's date, or the date on which the conditions of the above photo release were accepted (format:  MM / DD / YYYY).
2023 Annual IAR Youth Programs Registration Fee
You may submit the annual $20 / child registration fee to Br. Muhammad Samara, Br. Mahen M. Khan, or Sr. Tara Olhoft [for checks, memo:  "Annual IAR Youth Barcode"].

We will double-check this (and record the payment amount), so please make sure you provide the full name of the participant(s) with the payment.

Baaraka Allaahu feekum.
I understand that this form is incomplete until I submit the $20 fee. *
Required
A copy of your responses will be emailed to the address you provided.
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