Please enable JavaScript in your browser to complete this form. - Step 1 of 6I'tikaf Registration FormThank you for your interest. Those doing i'tikaf at the Islamic Society of Corona Norco must register using this registration form and provide a copy of a valid ID or Passport. Should you have any questions, please contact the following Taha Jilani at (310) 634-6211 Imran Chaudhry at (562) 716-5101Name *FirstLastEmail *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *NextAgeUnder 1818+I'tikaf Duration *I will be doing i'tikaf during last 10 days of RamadanI will be doing i'tikaf only a few daysFrom Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To Date *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PreviousNextEmergency Contact 1 *FirstLastPhone *Emergency Contact 2 *FirstLastPhone *PreviousNextConsent and Authorization: *Yes, I have read and accepted the termsNo, I do not consentIslamic Society of Corona Norco shall not be held responsible for any injury, loss, expense, or damage of any kind whatsoever suffered or incurred by any person who attends the i'tikaf program. By signing below, you agree to adhere to ISCN policies and procedures, and will not hold ISCN and its entities liable for any suffering that may occur. I assume all risks and hazards incidental to the conduct of the activities and release, absolve, and hold harmless ISCN and all its respective officers, agents, and representatives from any and all liability for injuries to myself arising during my stay at 465 Santana Way, Corona, CA 92881. In case of injury to myself, I hereby waive all claims against ISCN including all board members and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the attends the i'tikaf program.Authorized Signature *Clear SignaturePreviousNextMedical Release and Authorization: *Yes, I have read and accepted the termsNo, I do not consentI hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of myself, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of my life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for myself. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to ISCN and its affiliates including Directors, Coaches, and Team members to provide the needed emergency treatment prior to admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of my life and limb of myself.Signature *Clear SignaturePreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousSubmit