Step 1 of 3 33% Applicant InformationApplicants must be 18 years of age and olderName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email* Primary Phone/Home Phone*Secondary/Alternate PhoneMedical Conditions Dependents InformationDependents are youth between the ages of 15-18 and must be accompanied by a parent AT ALL TIMES. There are no arrangements for children under 15.DependentsFirst NameLast NameDate of BirthGenderAddress (if different from applicant) Emergency Contact InformationIn case of emergency, please include a contact which can be reached.Name* First Last Relationship*Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary/Home Phone*Alternate PhoneEmail* Family Doctor First Last Family Doctor's Phone NumberOHIP Number Itiqaaf Days RequestedDays Requested*Last ten (10) days of RamadanNight of the 27th of Ramadan to the last night of RamadanIf the two primary options are not what you are looking for, please select other and update field for dates you wish to be there for.I certify that the details i provided are true and accurate. I agree to abide by the rules and regulations set forth by the Muslim Association of Hamilton.* Yes By certifying above, you agree that you have read and understand the Itekaaf Program Policies available here. This iframe contains the logic required to handle AJAX powered Gravity Forms.