Please note that this email address will be associated with the primary contact for your household. A copy of all messages sent via the internal messaging system will also be sent to this email address.

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

This address will be used to verify your residency.

Phone

if you provide a mobile number, you are consenting to receiving automated calls and text messages with important information regarding your student to this number and acknowledge that the mobile carrier associated with this number may impose usage charges in connection with these calls and text messages. You can opt-out of the enrollment text messages anytime by replying STOP.

Parent/Legal Guardian *

First

Middle

Last

Please list the parent/legal guardian who will be the primary contact during the enrollment process as the first name in the section below. Each individual listed below will receive access to the school's Education Management System (EMS). Please use the correct capitalization for your names (e.g. Mohammad Ali).

Parent/Legal Guardian *

First

Middle

Last

Students Enrolling *

If you plan to enroll more than four students, please call 925-298-BMCC to add the additional names.

Student 1 *

First

Middle

Last

Please use the correct capitalization for your names (e.g. Mohammad Ali).

Student 1 Age *

Student 1 Gender *

Male
Female

Select Student 1 Program *

Student 2 *

First

Middle

Last

Student 2 Age *

Student 2 Gender *

Male
Female

Select Student 2 Program *

Student 3 *

First

Middle

Last

Student 3 Age *

Student 3 Gender *

Male
Female

Select Student 3 Program *

Student 4 *

First

Middle

Last

Student 4 Age *

Student 4 Gender *

Male
Female

Select Student 4 Program *

IMPORTANT: Read this document carefully before signing. This is a legally binding document. It is understood that this fully signed form must be submitted to BMCC before participate in any school related activities.

RELEASE WAIVER OF LIABILITY – I, the undersigned hereby indemnify and hold harmless, release, waive, discharge and covenant not to, bring any claim, lawsuit, action, litigation or demand in any form or forum against BMCC its affiliates , its administrators, teachers, students or any volunteers related with the school, all for the purpose hereby referenced as “releases,” for all liability to the undersigned, for any and all loss, injury, damage, act of God, war, civil unrest, sickness, terrorism, and any actions, claims, demands, damages, costs or expenses therefore, which I may have against releases arising out of, or in any way connected with my participation in any school-related activity.

SEVERABILITY: The undersigned further expressly agrees that the foregoing waiver agreement is intended to be as broad and inclusive as its permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. I also give permission to any one affiliated with the BMCC to provide or help provide any necessary medical assistance, care, emergency room service for me during the school related activities.

PHOTO RELEASE WAIVER: Occasionally, BMCC photographs and/or videotapes during the Summer Youth Programs. Photos and videos are used for many different purposes including publications, advertising, and promotional materials. Your signature gives your permission to use photos/videos of your child for promotional purposes.

AUTOMATIC BILLING AGREEMENT: This automatic billing (the "Agreement") is a legally binding agreement between you and Brentwood Muslim Community Center (BMCC). This agreement sets forth your rights and obligations with respect to automatic billing and payment of your monthly BMCC course program. By clicking the "I Agree" box, you are indicating that you have carefully read this agreement, understand it, and consent to be bound by all its terms and conditions. If you do not agree to the terms of this Agreement, you should stop the registration process now. Monthly Payments: Registrant authorizes a payment to BMCC from your credit card, debit/bank card or bank account in the amount of the current fee for the selected program and term. By accepting this Agreement, Registrant authorizes payments to BMCC from your credit card, debit/bank card, or bank account. Registrant authorizes automatic recurring payments for automatic renewal. Registrant understands that any automatic recurring payment method or renewal authorization will remain in effect until withdrawn by registrant or terminated by Provider.

The following is the payment of the summer program:

I have read this waiver hold harmless agreement and release of liability and fully understand its terms. I further understand that by signing this agreement that I am giving up substantial legal rights. I have not been induced to sign this by any person, any promise or representation, and I sign it voluntarily and of my own free will. I understand that this agreement cannot be modified or changed except in writing by the BMCC and that no oral modification or interpretation shall be valid.

Please check the box below and sign the application. *

I have read and agree with the terms and conditions.

Parent Signature

Payment Type *

Credit Card
Paypal

Credit Card *

Total

$0.00

Message

Summer Camp

Hikmah Summer Camps 2023

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