Application Deadline is on April 2, 2017
Address Line 2
Date of Birth
Home Telephone Number
Which ethnical Muslim Community do you associate yourself with?
(Ie: JCC, MIC, Mahdieh, al-Mahdi, Afghan center, Bilal Community, A'rassool, Shiane Haideri, MYM, CCMM, CMM, Imam Hussein Foundation, etc...)
What drivers license do you have?
Will you be driving with your own vehicle to the retreat?
If yes, how many additional people can you take with you?
Health Card Number
Do you have any allergies we should know about?
If yes, please explain.
Do you have any current medical conditions we should know about (ie: disabilities, dietary restrictions, access problems)?
If yes, please explain.
Emergency Contact #1 - Name
Emergency Contact #1 - Relationship to you
Emergency Contact #1 - Phone Number
Emergency Contact #2 - Name
Emergency Contact #2 - Relationship to you
Emergency Contact #2 - Phone Number
Education: Please state the education institution(s) that you currently attend or have recently graduated from
Advanced academic certificates, diplomas and degrees
Employment: Please provide details of any employment
i.e. name of employer, Dates of employment (From-To), position, brief description of work
Extracurricular Activities: Please list extracurricular activities you have been or are involved with
i.e. name of organization, dates of involvement (From-To), position, brief description of involvement
Describe your greatest accomplishment - what were the objectives, how did you set these objectives and how did you achieve them?
Have you taken similar courses or have you attended a similar camp before?
If yes, please list course/camp, location and date(s)
What are you passionate about, why?
What are you most afraid of?
Why do you want to participate in this retreat? What do you hope to get out of it?
Give a time when you set a goal and weren't able to achieve it
What was the goal, what happened, why do you think you weren't able to achieve it?
Give a time when you set a goal and were able to achieve it
What was the goal, what happened, how did you achieve it?
What motivates you in life?
Think about intrinsic motivation as well as external motivation, what gives you the fuel to be at your best?
What inspires you in life?
Think about the elements around you that inspire you to act?
What size t-shirt do you wear?
How did you hear about this retreat?
Poster at a center
Organization email list
Personal email list
Word of mouth
If you were referred to the retreat, who were you referred by?
Please enter any two digits
This box is for spam protection -
please leave it blank