Registration – Camp Al-Hilal

Child First Name*

Child Last Name*

Email*

Phone*

Gender*

Female

Male

Date of Birth(mm/dd/yy)*

Age*

Street Address*

City*

State*

Zip*

Are you a previous attendee?*

Yes

No

Nearest Mosque*

Father`s Full Name*

Father`s Email Address*

Father`s Phone Number*

Place of Employment*

Mother`s Full Name*

Mother`s Email Address*

Mother`s Phone Number*

Place of Employment*

Emergency Contact 1(Full Name)*

Emeregency Contact 1 Relationship*

Emeregency Contact 1 Phone*

Emergency Contact 2(Full Name)*

Emergency Contact 2 Relationship*

Emergency Contact 2 Phone*

Medical History*

Please explain if you selected "Other" or any area of concern that you have selected otherwise type "None"*

Any Activity restrictions? If none then type "None"*

History of emotional or behavior problems? If there is none then type "None"*

Recent operations/injury/illness?*

Has the camper been recently exposed to a contagious disease(such as covid, chicken pox or strep throat)?*

Yes

No

Any food, insect, plant or drug allergies?*

Any medication(prescription or over-the-counter) that your child is currently taking and will be taking while at camp?*

Yes

No

Drug 1

Frequency/when/how should it be taken

Used for what condition:

Drug 2

Frequency/when/how should it be taken

Used for what condition:

Medicaid Number

01 Code

Name insurance is under

Blue Cross/Blue Shield: Effective Date

Subscriber

Group#

Service#

Contract#

Other commercial insurance company name:

Policy Holder`s Name

Effective Date

Complete Address of Company

Shirt Sizes

S

M

L

XL

Shirt Type

Long Sleeve

Short Sleeve

Bus Location*

Not Needed

IAGD

Parent Electronic Signature*

Date*

Electronic Siganture of Camper*

Date*