Young Muslim Explorers Class

Young Muslim Explorers Class 9/20

Young Muslim Explorers Class

* Start Date: 09/20
* Fees: $90/student
* Duration: 6 Weeks

Parent Email Address ***Valid email address required***:

Parent Full Name:

Parent Phone #:

Emergency Contact Name:

Emergency Contact Phone #:

Address

Name of Child/ren Physician or Health Clinic

Address

Phone

Hospital Preferred for Emergency Treatment

Health Insurance Policy Name & Number:

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Please make sure the number of Children Information Matches with the Total number of Children below!

Total Number of Child(ren)

Child(ren) Information

Child Full Name	Date of Birth	Allergies	Attended last year class

I hereby release CVIC and its staff and agents from any and all liability, claims or damages.
I hereby waive any and all claims or actions on behalf of myself, my heirs, assigns or successors in interest with respect to CVIC and my child(ren) participation in the same.
I hereby give CVIC permission to photograph or videotape my child while in attendance at the camp for the production of camp materials/media for informational and other appropriate uses.
CVIC has the right to suspend or dismiss any child for violation of camp policies and/or directives as deemed necessary by Camp administration.
I hereby give permission for my child to be transported in a vehicle for scheduled offsite field trips.
CVIC reserves the right to make changes in the program as necessary.

By typing my initials below, I, the undersigned, confirm that I have read and fully understand the information provided above.

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