Waiver and Release Forum

As a parent/guardian, I understand that participation in the DFW Summit: Revival of the

Youth Worker, hosted by MAS Youth and IANT Youth for DFW Youth Council involves a
certain degree of risk. I have carefully considered the risk involved and have given my
son/daughter my consent to participate in the DFW Summit: Revival of the Youth
Worker. I also agree to pay the retreat fees. I am responsible for my own transportation if I miss
the group transportation. This health history is correct and complete as far as I know. The person
herein named has permission to engage in all camp activities except as noted.
By submitting this health form I give the permission to DFW Summit: Revival of the
Youth Worker to provide, seek, and consent to routine health care, administration of prescribed
medications and emergency treatment for my child as may be necessary, including, but not
limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for
the DFW Summit: Revival of the Youth Worker to arrange related transportation.
I agree to the release of any records necessary for treatment, referral, billing or insurance
purposes.
It is my intention that the camp be treated as acting in loco parents if the person herein named is
a minor. Further, it is my intention that the appropriate representatives of the camp be treated as
"personal representatives" for the purposes of disclosing protected health information pursuant to
the privacy regulations promulgated pursuant to the Health Insurance Portability and
Accountability Act of 1996. I hereby agree (pursuant to 45 CFR 164.510(b)) to the disclosure to
DFW Summit: Revival of the Youth Worker representatives of the protected health
information of the person herein described, as necessary: (i) to provide relevant information to
the camp representatives related to the person's ability to participate in camp activities; and (ii) in
the case of minors, to provide relevant information to the camp representatives to keep me
informed of my child's health status.
In the event I cannot be reached in an emergency, I hereby give permission to the physician
selected by the camp to secure and administer treatment, including hospitalization, for the person
named above.
I allow MAS Dallas, Muslim American Society, and IANT, Islamic Association of North Texas,
to use my son's/daughter's pictures for educational, promotional and/or any other purpose chosen
by the organizers.
By submitting this form, I, the parent/guardian of the youth participating in DFW Summit:
Revival of the Youth Worker understands that my youth is expected to agree and abide by
all the rules below! I agree to be responsible for all expenses incurred in sending him/her home if
my youth refuses to follow the rules below or other rules set at the camp
1. Comfortable appropriate clothes is highly advised and very recommended. The camp will
include intense activities. Sweat pants, long shirts, loose articles of clothing is required.

2. Islamic behavior is to be observed at all times, which includes polite speech, respecting
elders, listening to those in authority, respecting the other participants.
3. All youth workers must stay on the camp property at all times, and within the areas of the
property that are designated for our use. Unless permission is approved by the
organizers.
4. No weapons of any sort.
5. No drugs of any sort, including tobacco products.

Anyone who brings items 4 and 5 can be subjected to local law enforcement immediately
and the matters will be in the hands of the law.
* I understand that participation in the DFW Summit: Revival of the Youth Worker,
organized by MAS Youth and IANT Youth for the DFW Youth Council, involves a certain degree
of risk. I have carefully considered the risk involved and have given my son/daughter permission
to participate in the DFW Summit: Revival of the Youth Worker and I release all
organizations and all of its employees, officers, volunteers from any liability that could result
from my youth's participation in the DFW Summit: Revival of the Youth Worker .
I have read, understand, and initialed all waivers that apply to my child. Camper understands the
above rules and regulations.
Campers Name _______________________________________________________
Campers Signature ____________________________________________________
If younger than 18

Guardian Name _______________________________________________________

Guardians Signature ___________________________________________________
Date_________________________________________________________________

Check list for the Youth Retreat!

Personal Items

Sleeping Bag, sheets, and pillow Mattress only, nothing else provided
at the retreat
Jacket and warm articles of clothing
Notebook and writing utensil
Water Bottles
Toothbrush, toothpaste, shampoo, soap and towel
Medium to large size flash light with NEW batteries
Umbrella Just incase
Hand sanitizer
Tissues/Kleenex
Snacks!
Thick Prayer rug
Quran to follow for Qiyam
Extra shoes/sneakers and socks
Loose, outdoor and comfortable clothes
Brothers and Sisters there will be a lot of physical activity
o sweat pants are your best choice.
Prayer Clothes (Sisters Abaya/Prayer Skirt/Hijab Brothers long pants
and shirts)
PJs
Jacket
Sweater