Muslim Association of Hamilton March Break Camp 2017 - Registration form
Full Name *
First, Middle & Last Name
Your answer
Gender *
Date of Birth *
YYYY/MM/DD
MM
/
DD
/
YYYY
Age of child? *
must be between 11-17
Health Card Number *
Your answer
Special need or Allergy?
Please list if any
Your answer
Parent's/Guardian's Full Name *
Your answer
Parent's/Guardian's Address *
Street # and Street Name
Your answer
APT *
Apt / Unit
Your answer
CITY, PROV *
City
Your answer
POSTAL CODE *
Postal Code XXX XXX
Your answer
How can we reach you? *
Tel? Cell? Work?
Your answer
E-Mail
Your answer
Emergency Contact *
Emergency contact Full Name
Your answer
Emergency contact's Relationship to child? *
Emergency Contact's Telelphone? *
Your answer
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