Brothers Quran Revision Day

Fill out the below form by Sunday, September 14 in order for your spot to be reserved. The fee of $100 is due on the deadline as well. Please send payments to 571-594-4127.

You MUST include your first and last name and “Quran Revision Day” in the Zelle Description!

Name

First Name

Last Name

Phone

(###)

###

####

Age

Juz Category

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have submitted the payment to the Zelle as instructed and included my first and last name in the Zelle descriptions. Zelle: 571-594-4127

Yes

I will do that right now

Permission to be Photographed

Please read the agreement carefully before signing. A Parent/Guardian must sign on behalf of minors. Photograph, Testimonial and Interview Release In exchange for good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby grant to Imam AlKisai Institute of America, its legal representatives, successors and assigns, and those acting with their authority and permission the right and permission to use, re-use, publish, re-publish, and copyright (in Imam AlKisai Institutes own name and otherwise) testimonials (written by me or attributed to me), interviews (written by me or attributed to me), and photographic portraits, pictures, images and/or likenesses of me or in which I may be included (in whole or in part, or composite, or distorted in character or form, without restriction as to changes or alterations), in conjunction with my own or a fictitious name, made through any medium, and in any and all media now or hereafter known throughout the world in perpetuity. All rights, licenses and privileges herein granted to Imam AlKisai Institute are irrevocable and not subject to rescission, restraint or injunction under any circumstances. I hereby waive any right that I may have to inspect or approve the finished product, or products and the advertising copy or other matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless Imam AlKisai Institute from and against any claims, damages or liability arising from or related to the use of any of the aforementioned material, including but not limited to any liability by virtue of any editing, blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking, recording, editing, processing, publishing or distribution of said testimonials, interviews, pictures, portraits, images and/or likenesses including, without limitation, any claims for defamation, invasion of privacy, right of publicity or violation of any other right. I hereby acknowledge that the compensation provided does not include any monetary compensation or tangible goods or services and that none are due to me for granting this release. I hereby warrant that I am of full age and have the right to contract in my own name. I have read this Release prior to its execution, and I am fully familiar with the contents thereof. This Release shall be binding upon me and my heirs, legal representatives, and assigns. If signing as parent or guardian, I hereby warrant and represent I am the parent or legal guardian of the named minor and have authority to and do hereby consent to this Release on his/her behalf and will be responsible for any damages incurred by Imam AlKisai Institute resulting from the minor’s breach or renunciation of this Release.

Signature

Brothers Quran Revision Day

Imam Alkisai Institute