Muslim Social ServicesWaterloo Region

Fall - Al Nour Project

Website

Participant's full name *

Date of birth *

Gender optional

Email address *

We'll email a confirmation and a QR check-in code.

Phone Number *

Emergency contact name *

Emergency contact phone number *

Accessibility or medical needs optional

Languages spoken optional

Parent / guardian full name *

Relationship to participant optional

Parent / guardian email address optional

Parent / guardian phone number *

Please state your complete address *

Please state your residential postal code *

What is your current status? Select the one that best represents you. *

Have you previously attended the Al Nour Project Program? *

Will you be able to attend all sessions? *

Dietary Restrictions: *

Do you have any allergies or nutritional requirements that we should be aware of? Note: Snacks will be available during the sessions. We want to ensure that all snacks are safe and suitable for our me *

What do you need to feel comfortable during the sessions? (i.e. confidentiality, short breaks, raising hands before we share, having time to socialize with peers, engaging activities, weekly homework) optional

Do you have any concerns about joining this program? If yes, please share these concerns so that we can address them with how we deliver the program. optional

Is there anything else you'd like to share or suggest to help us improve our programs? optional

I consent to photos/videos taken during the program being used by MSSWR. *

Waiver & consent *

Disclaimer Form Dear Parent/Guardian and Participants, This is a disclaimer form regarding any injuries to take place during any MSS events. I understand and acknowledge that my participation in activities, events, or services provided by Muslim Social Services Kitchener Waterloo (“the Organization”) may involve certain risks and dangers. By voluntarily participating in these activities, I hereby agree to release and discharge the Organization, its employees, volunteers, agents, and representatives from any liability, claims, demands, actions, or causes of action arising out of or related to any injuries, incidents, or accidents that may occur during my participation. Assumption of Risk: I understand and accept that there are inherent risks associated with the activities provided by the Organization. These risks may include, but are not limited to, physical injuries, property damage, or other losses. I voluntarily choose to participate in these activities, fully aware of the potential risks. Indemnification: I agree to indemnify and hold the Organization harmless from any claims or actions brought against them by third parties arising out of my participation in their activities. • Muslim Social Services are not accountable for any injuries during event hours. • I hereby grant permission for my child(ren) to be included in any pictures and/or video connected with the organization publications, and other programs. I give program coordinator(s)/facilitator(s)/supervisor(s) and volunteer(s) the permission to send me announcements, information and publications on my email address(es) and/or phone number(s) I provided. • If you're not picking him/her up yourself please clarify that and let us know ahead of time.

I have read and agree to the waiver above.

Type your full name to sign *

480 Charles St E, Kitchener ON · www.msswr.org