ICEV Youth Night Registration Form $5/person  
Qiyaam Timing: Friday, November 23rd, 2018 7:30 PM- 12:30 AM
Address: Islamic Center of the East Valley @ 425 N Alma School Rd. Chandler, AZ 85224
Cost: $5/ Person
Contact us at: (480)628-8971
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Email *
Youth Last Name: *
As if mohammed
Youth First Name: *
one person per form.
Any Medical problem (allergies) you may have: *
Required
Please select  youth gender: *
Required
Youth Age: *
Contact Phone Number: *
Parents Acknowledgement *
Children less than 10- years must be accompanied by their parents all time.
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We, the parents of the youths (under 18) listed on this form, who plan to participate in ICEV Youth night program which require the youth to stay until 12:30 at the facility hereby waive all claims against ICEV and its officers, directors, employees and volunteers in case of any accidents, incidences or medical emergency during their overnight stay. We also agree that we will assume full financial responsibility and pay for any damages to ICEV facility, equipment, furniture etc. caused by our children. *
Parent Full Name as signature
Print your full Address *
Emergency Contact number other than the person staying in ICEV *
Fee Paid (Leave alone until - fee collection on 11/23/18)
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A copy of your responses will be emailed to the address you provided.
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