MCC Youth Program 11-13 Yrs Old Participant's Name* First Last Birthday* MM DD YYYY Grade*5th6th7th8thParent's Name* First Last Parent's Email* Parent's Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact* First Last Emergency Phone Number*If your child has any allergies please list:please specify medications in case of an allergic reactionLIABILITY RELEASE AND PARENTAL CONSENT* I hereby grant permission for my child to be a member of the Youth Program at MCC. I hereby release MCC from any liability and all of its personnel, employees, adult leaders, volunteers and representatives from any claims for unintended or unexpected accidents which might occur during participation in youth events or traveling to or from said events. In granting this permission and release, I specifically recognize that my child may from time to time be transported to events by private vehicles operated by leaders or volunteers. In such regard, I specifically release and will hold harmless MCC, their personnel, employees, adult leaders, volunteers, agents and representatives from all liability which may arise because of such transportation whether or not organized by MCC. My child has my permission to go on all field trips and to all events with MCC Youth Group unless I specify otherwise in writing. PHOTO RELEASE: I hereby grant Muslim Community Center of Charlotte, the permission to use my child’s photographs, video, and other media in any and all of its publications, including bulletin boards and website entries. I waive any right to royalties or other compensation arising or related to the use of the photographs or videos.