Camp Al Hilal Registration

Eligibility: Ages 9-17
Deadline: June 3, 2024 (if space is still available)
Cost: $390

Please note change in registration policy. Registration will no longer be first come first serve. All applications will be reviewed. Camp Al-Hilal reserves the right to accept or deny any application for any reason. Any applicant not accepted will be given an immediate full refund

IMPORTANT Please read our Behavioral Policy! Please fill out this mandatory behavioral policy questionnaire if you haven’t done so already.

If you have any issues with registering please email Br. Ali Ahmed at [email protected].

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Child First Name*

Child Last Name*

Email*

Phone*

Gender(Brothers registration is filled)*

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*

Hay Fever/asthma/wheezing

Convulsions/seizures

Cold/sore throats/ear aches

Trouble passing urine/stools

Menstrual problems

Heart conditions

Bedwetting

Sight problems

Speech problems

Shortness of breath

Hearing problems

Dental problems

Skin rashes

Diarrhea

Sleep walking

None

Other

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*

Address

If you are a human, do not fill in this field