Register

REGISTRATION INFORMATION FORM

MAKE SURE YOU COMPLETE ALL SECTIONS BEFORE YOU CLICK SEND:

Personal registration information, Medical / Insurance information,
Guardian / Parental Release

Once you complete this form and press REGISTER,
return to the registration page to complete online payment:

$150.00 Pre-Registration | $175.00 Late Registration.

* required fields

 

PARTICIPANT INFORMATION
First Name*
Last Name*
Address 1
City*
State*
Zip Code*
Email*
Telephone*
Gender* Male
Female
Age*
Date of Birth*
Grade Level
Hobbies/Interests
How many times have you attended Kamp Khalil?*
T-Shirt size* S
M
L
XL
XXL
Sleeve Length* Short
Long
Masjid Name
Name Parent(s)/Guardians*

Please choose one or more of the following. Answer in at least 300 words.

  1. What are the qualities and characteristics of a good leader? 
  2. How does Islam prepare you for a position of leadership?
  3. How do you intend to contribute to the growth of Islam in America?
Essay
MEDICAL / INSURANCE INFORMATION
Primary Physician Info
Name*
Address
City
State
Zip Code
Phone*
Health Insurance Info
Carrier Name*
Insurance Tel*
Allergies and pre-existing conditions*
GUARDIAN / PERMISSION RELEASE
Guardian Release* I am the parent or legal guardian of the participant named above. I hereby release the Kamp Khalil, their agents, employees, and volunteers from any and all liability for all personal injuries known or unknown that the youth named above may incur due to reasons unrelated but not limited to negligence by participating in activities conducted, sponsored, or associated with the event stated above.
In the event of an emergency I, or my spouse, may be reached at the following numbers:
Emergency #1*
Emergency #2

Kamp Khalil strives to provide a well rounded, informative and fun filled week of activities for all campers.  All campers are expected to participate in all of the planned activities, including the outdoor, physical activities, such as volleyball, dodge ball, basketball, canoeing, as well as other games and competitions. 

Kamp Khalil does not currently have the medical facilities to accommodate campers who may have an illness or condition that requires special attention. Campers that have undergone surgery within the last 12 months will need to submit a medical release form signed by their physician. Campers that are pregnant, are wearing a cast, or have any other medical or physically restricting condition will not be able to participate in Kamp Khalil.  Please note that the campground is not handicapped accessible.

Please fully disclose any health issue of your camper, no matter how minor it may seem to you.  Your camper’s health and well being are a vital concern for us.

Kamp Khalil cannot and will not assume responsibility for any campers who do not fully disclose any medical conditions which may impede their ability to fully participate in all activities.  Please govern yourself accordingly.
Physician Release* Also, in the event that I cannot be reached in the case of emergency, I do hereby authorize a physician selected by the coordinator of this event to administer emergency treatment including medications, diagnostic tests, surgery, or other medical intervention deemed necessary by the physician.
Name of person to release my child to at the conclusion of event**
Telephone for the above listed individual**
Your Name*
Todays Date*
Signature By checking this box, I disclose that I have read this release and understand all its terms. I execute it voluntarily on behalf of myself and the participant named above and with full knowledge of the significance to bind all persons. In witness whereof, I have signed this release on the date indicated above.