Muslim Social ServicesWaterloo Region

Fall - Tutoring Program

Website

Participant Information

Participant's full name *

Child name

Date of birth *

Gender optional

Email address *

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

Phone number optional

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 optional

Parent / guardian phone *

Program Information optional

What is your grade as of Septemeber 2026? *

What subject would you like help in? *

Math English

What areas do you need most help with? *

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