Applicant Date of Birth:
Parent / Guardian Name:
Brief Medical History
I authorize ARKanum to make any medical decisions necessary to ensure proper medical treatment for the participant named above in case of any circumstances. I will assume all expenses related to the medical care for myself and/or my children, in the event that no health insurance is provided. I certify that I have provided the most current and up to date medical information regarding the participant. Failure to inform of any medical conditions is not the responsibility of ARKanum, and thus, ARKanum will not be held liable in these circumstances.
I acknowledge that there are risks inherent in any children’s program, including but not limited to injury arising from: participation in activities; children’s failure to follow instructions of teachers and supervisors; communicable illness; and independent acts of third parties not under the control of mentors and staff. I acknowledge that all risks cannot be prevented, and assume those beyond the control of ARKanum & ISBCC staff. Further, I hereby fully and forever discharge Arkanum & the Islamic Society of Boston Cultural Center from any and all claims or expenses of any nature relating to injury of any type suffered during or otherwise arising from any program. In order to minimize risks to my child or other participants, I will take responsibility to see that my child is properly prepared for all activities and is in good health prior to any program or event.
In case of medical emergency, I understand that every reasonable attempt will be made to contact me, my family physician, or the emergency contact named below. However, in the event that I or my named contacts cannot be reached, I give my permission to the mentors in charge of ARKanum at the Islamic Society of Boston Cultural Center to secure emergency medical treatment for my child. I agree to pay for any charges for emergency medical treatment that are not covered by my personal health insurance. This acknowledgment applies to any programs or events of ARKanum for which I may subsequently register my child.
By signing this form, I (we) hereby authorize Arkanum, It’s Officers, Representatives, Employees & Agents, in the case of any illness or medical emergency to consent to necessary medical care and treatment for me should I be unable to make a decision.
Keeping in touch with the community is a wonderful part of ARKanum! I hereby grant ARKanum the right to disclose photographs of my child(ren) on social media platforms as well as advertisement and marketing purposes, including but not limited to Facebook, Email, and the ISBCC website.
Program Rules and Regulations
At ARKanum, we truly value our sense of commitment, unity, and becoming a part of the change that we want to see in our future generations! With that being said, we kindly ask that our participants abide by a few simple requests in order to develop a successful program for years to come!
In addition to the policies mentioned above, please note that dismissal at the end of each session takes place at the time mentioned in the weekly schedule. All ARKanum personnel are not responsible for any of the children after the mentioned time.
By signing my name below, I certify that I have read and understood the above information. Any questions concerning these policies have been discussed, and my signature below certifies my understanding and agreement with these policies.
Parent / Guardian Name :
First name *
Last name *
Register as *
Email address *
Date Of Birth *
Address Line 1 *
Address Line 2 *
Zip Code *
School Name *
Type Of School *
Register an account for one of parents or both (please choose from the below selections)
I already have a parent account on arkanum.
Register account for only father.
Register account for only mother.
Register account for both parents.
Check and Relate
First name *
Last name *
Email address *
Marital Status Of Parents
Prefer not to answer
Number Of Siblings
Is the applicant currently living with anyone other than his/her parents? *
I Agree To Medical Consent Form (Please click here to Update & Review). *
MAS Boston project