Youth Circles Application – 2024 Youth Circles are offered for boys and girls (Grades 6-12). To register more than one youth, please fill out a separate application for each youth.Choose the Youth Circle you would like to join(Required)Fees: $200/person covering September - May Girls (Grades 6 & 7) - Wednesday 6-7:30 pm Girls (Grades 8 & 9) - Wednesday 6-7:30 pm Girls (Grades 10 and up) - Tuesday 6-7:30 pm Boys (Grades 7 – 9) - Wednesday 6:30-7:30 pm Boys (Grades 10 & 11) - Sunday 9-10 am Boys (Grades 10 and up) - Saturday after Fajr Total Youth InformationYouth Name(Required) First Last Youth Email(Required) Youth PhoneGender(Required)MaleFemaleSchool Year(Required)6th7th8th9th10th11th12thSchool Type(Required) Public Islamic Other Do you attend any Islamic part-time program?(Required)Weekend or after-school program What are your main hobbies and interests?(Required) Why are you interested in MAS Bay Area Youth Circles?(Required)Parent InformationFirst Parent Name(Required) First Last First Parent Phone(Required)First Parent Email(Required) Second Parent Name First Last Second Parent PhoneSecond Parent Email Emergency ContactPlease enter contact information for an emergency contact (different than parent) who we can contact in case parents cannot be reached.Name(Required) First Last Phone(Required)Consent(Required) I agreeI hereby give consent for me and/or my child to participate in the full program and all activities including surveys used for the purpose of future programming unless I advise you in writing. To the best of my knowledge, I and/or my child are in good health and I will notify MAS if he/she is exposed to any infectious diseases.Consent(Required) I agreeI release and agree to indemnify and hold harmless MAS youth workers, volunteers or assigns from any liability concerning my and/or our child’s involvement in camp activities. In case of surgical emergency, I hereby give permission to the physician selected by the director, to hospitalize, to secure proper treatment for and to order injection, anesthesia, or surgery for my child, as named on this form. Every effort will be made to contact the parent/guardian in the case of emergency.Photography Consent(Required)I give permission for MAS to use any photographs of me and/or my child for promotional material. Yes No Payment InformationFees: $200 covering September - MayCredit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Δ
