Summer Camp 2023- Dar Al-Hijrah USA

Parents' Information
1st Primary Guardian
Name*
First Last
Relationship to Child*
Email
Phone Number*
2nd Primary Guardian
Name*
First Last
Relationship to Child*
Email
Phone*
How did you hear about DAH Summer Camp?*
- Social Media
- Email
- Website
- Friend/Family
- Other
How Many Children Are You Enrolling?*

Emergency Contact/ Authorized Pickups
1st Contact/Pickup
Click next if not applicable
Name
First Last
Relationship to Child
Phone Number
2nd Contact/Pickup
Click next if not applicable
Name
First Last
Relationship to Child
Phone Number

Child 1
Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require*
Fill N/A if this does not apply to your child
Allergies*
Fill N/A if this does not apply to your child
Camp fee
This fee covers the costs of one child only.
Price:

Child 2
Good news! You've recieved a $50 discount on your second child.
Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require*
Fill N/A if this does not apply to your child
Allergies*
Fill N/A if this does not apply to your child
Camp fee
This fee covers the costs of one child only. (DISCOUNTED PRICE)
Price:

Child 3
Good News, your third child is discounted as well!
Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Camp fee
This fee covers the costs of one child only.
Price:

Child 4
Good News, your fourth child is discounted as well!
Name*
First Last
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Existing medical conditions, medications, and/or special attention your child may require*
Fill N/A if this does not apply to your child
Allergies*
Fill N/A if this does not apply to your child
Camp fee
This fee covers the costs of one child only. (DISCOUNTED PRICE)
Price:

Total
$0.00
Payment Information
Total
$0.00
Early Bird Discount Code

Don't forget your Early Bird discount! MayEBCamp20 for May. JuneEBCamp10 for June.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00
Consent*
I agree to the privacy policy.
I affirm that the above information is complete and true to the best of my knowledge. I verify and agree that my child must abide by the rules of the program and must participate fully in the program. I understand that Summer Camp of DAH reserves the right to request any participant to leave the program if a participant's conduct is determined to be disruptive to the program and fellow registrants. I understand that the organizing institutions, administration, their officials, and staff are not responsible for any injuries or loss of property that may occur. In the case of an emergency where I cannot be contacted, I authorize the administration to seek medical attention and/or administer any needed emergency procedures for the registrant. I also authorize my insurance information to be used and I authorize Dar Al-Hijrah Islamic Center or the insurance company to release any information required to process the claim. In such a case, I understand that I am financially responsible for any due balance. I understand that my child(ren) will not be allowed to begin or continue with the program if payment in full is not submitted prior to the beginning of their first session (or first session of next month).
Signature*
Type in your name to acknowledge the completion of this application and payment
Parent/Guardian Signature Date

DAR AL-HIJRAH ISLAMIC CENTER
GIVE NOW

REGISTER YOUR CHILD HERE TODAY!

Step 1 of 7 - Parents Information

Parents' Information

1st Primary Guardian

2nd Primary Guardian

Emergency Contact/ Authorized Pickups

1st Contact/Pickup

2nd Contact/Pickup

Child 1

Child 2

Child 3

Child 4

Payment Information