Summer Camp Application

UMM Summer Camp Registration Form

Today's Date:

Name

Email

Parent or Legal Guardian (status):

Mother Father Grandmother Grandfather Aunt Uncle Other

Your Age:

Address

Phone #

How many children will be attending?

Names & ages separated by commas

Child's Physician's Name

Health Care Provider Info

Medical Insurance Provider

Policy Number

Special Needs

Allergies

Medical or Dietary information

Do you authorize the following activities select all which apply:

Obtain Emergency Medical Care‎ Minor First Aid Procedures‎ Walks and Trips‎ Swimming (if applicable)‎

Emergency Contact 1

Emergency Contact 2

Person to whom child(ren) can be released to (more than one separate by commas)

Would you be able to make any donations/volunteer any time

Yes No

Additional Comments:

Provide each student's school photo or passport type photo for identification purposes

Add files

Drop files anywhere to add

Digital signature

Clear

Terms of Service

I have read The Summer Camp Application. I swear by Allah (swt) I agree to the terms of service.

Memo of Understanding: It is understood that by submitting this form you swear by Allah (swt) you have answered all questions fully and truthfully.