February 2023 Umrah Reservation Form (Simple)

Email Address *

Cell Phone *

Home Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Airport you are flying from *Detroit (DTW)Chicago (ORD)Other

Please list the airport you are flying from

Total Number of Passengers *

How many of these passengers are aged 12 and below *

Passenger Details

Please enter this information exactly as it appears on the passenger's passport (where applicable). These fields must be filled out for every passenger in your reservation. For families, we require email addresses and phone numbers for all adults on your reservation.

Surname *

Given Name(s) *

Date of Birth *

Email Address (if applicable)

Phone (if applicable)

Gender *

Marital Status *

Country of Birth *

City of Birth *

Occupation *

Country of Citizenship (for the passport you are using to travel) *

Passport Number *

Passport Issue Date *

Passport Expiration Date *

To avoid issues, please ensure your passport does not expire before August 2023.

Photograph *

No file chosen

Please upload a photograph that meets these these specifications (click here).

Allowed file types are .jpg, .jpeg, .png, .gif, and .bmp.

Please contact umrah@refinedheart.com if you need assistance with uploading your photograph.

Passport *

No file chosen

Please upload a clear and legible scan or photograph of your passport's biographical data page (click here for an example).

Legal Status in the United States

No file chosen

Only required if this passenger is not a US Citizen

Please upload a clear and legible scan or photograph of your proof of legal status in the United States. This may be a Lawful Permanent Resident Card (Green Card), an Employment Authorization Document (EAD), or other proof of valid non-immigrant status. Multiple documents may be combined and uploaded as a single pdf file.

Any medical conditions, dietary restrictions, special accommodations or other information you would like to share about this passenger:

Please provide the following information for someone who is not traveling with you, to be contacted in case of an emergency.

Name *

Relationship

Email Address *

Phone *

Pre-Trip Curriculum Participation

In order to provide maximum benefit, we have carefully designed a pre-trip curriculum consisting of weekly 30-minute virtual sessions, assigned readings, quizzes, goal-setting activities, and a pre-departure meeting with Shaykh Ashhar. The pre-trip curriculum activities are expected to commence in early January.

Refined Heart Umrah: Release, Indemnification, and Waiver

I voluntarily elect to participate in the Refined Heart Umrah (“Umrah Trip”) organized by Refined Heart NFP (“Refined Heart”). I hereby agree to accept and assume any and all risks of property damage/theft, personal injury, and/or illness arising from—or otherwise related to—participation in the Umrah Trip.

I understand that Refined Heart does not insure participants and participants who want to be covered must obtain their own insurance. I understand that Refined Heart asserts lack of responsibility and liability for any injury or illness resulting from participation in the Umrah Trip.

I, on behalf of myself, my spouse, next of kin, my minor child(ren)/ward(s) attending the Umrah Trip, and any successors and assigns, hereby forever release, indemnify, and hold harmless, Refined Heart and its directors, officers, employees, volunteers, board members, and/or agents (and their successors and assigns) from and against any and all claims, accidents, injuries, illnesses, losses, suits, demands, causes of action, damages to person or property, property theft, or costs (including attorneys’ fees), which I now have or may hereafter have, arising out of, resulting from, or relating to my or my minor child(ren)/ward’s participation in the Umrah Trip. These injuries or outcomes may arise from my own or other’s actions, inactions, or negligence. Nonetheless, I assume all risks of my participation in this Umrah Trip, whether known or unknown to me.

I hereby consent to receive medical treatment (for myself or my minor child(ren)/ward) which may be deemed advisable in the event of injury, accident, or illness during the Umrah Trip. I agree to be financially responsible for any costs incurred as a result of such treatment.

I understand that this release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.

I understand that Refined Heart reserves the right to discontinue my (or my minor child(ren)/ward)’s participation in the Umrah Trip, and that Refined Heart may ask me (or my minor child(ren)/ward) to leave the Refined Heart Umrah group if, in its sole discretion, Refined Heart determines that I (or my minor child(ren)/ward) have breached any applicable rules governing participation in the Umrah Trip, or that my (or my minor child(ren)/ward)’s participation is interfering with the overall purpose of the Umrah Trip. I agree to comply with any such determination and to release, indemnify, and waive any claims arising out of—or relating to—such decision.

COVID-19 Notice: I understand that Refined Heart, in its discretion and consistent with public health guidelines, may impose certain requirements on Umrah Trip participants to limit the spread of SARS-CoV-2. I understand that, notwithstanding these steps, there is a risk of contracting the virus in connection with my (or my minor child(ren)/ward)’s participation in the Umrah Trip. Consistent with the foregoing, I hereby release, indemnify, hold harmless, and otherwise waive any claims against Refined Heart relating to contracting the virus.

Group Decisions During Umrah Trip

As a traveler, I understand that situations might arise during the Umrah Trip that will require decisions of a religious nature to be made for the entire group. In these situations, I will defer to Refined Heart's appointed representative(s) and follow their decision to ensure a smooth experience for the entire group.

Signature *