Skip to content
follow us on social media
Search for:
Toggle Navigation
ABOUT US
Who We Are
Our Impact
Our Team
Volunteer With Us
OUR WORK
CLASSES
NEW
ANNOUNCEMENTS
Search for:
DONATE
DRIVE 2025
DRIVE 2025 – Staff / Counselor / Speaker
Yousif Fawaz
2025-05-01T11:46:28-04:00
1
Personal Information
2
Medical Information
3
Consents & Agreements
4
Payment / Submission
Registering as:
(Required)
Registering as:
Counselor
Staff
PERSONAL INFORMATION
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Gender
(Required)
Gender
Male
Female
Date of Birth
(Required)
MM slash DD slash YYYY
MEDICAL INFORMATION
Past medical history
(Required)
EX: asthma, seasonal allergies, tonsillitis, strep throat, croup
Please list any recent hospitalizations if any
(Required)
EX: appendectomy 2012
Current medications
(Required)
EX: Albuterol; 90mcg; 1-2 puffs every 6 hours as needed
Name
Dose
Frequency
Add
Remove
Other issues
(Required)
Please check any medications the registered nurse can administer to you at camp if needed:
Tylenol
Benadryl
Motrin
Antibiotic Ointment
Hydrocortisone Cream
Stool Softener
Please provide a picture of your drivers license
(Required)
Max. file size: 80 MB.
Please provide a copy of the insurance card attached to this form in case of an emergency
(Required)
Max. file size: 80 MB.
CONSENTS & AGREEMENTS
Non-Disclosure Agreement
(Required)
I agree to the Non-Disclosure Agreement
I. CONFIDENTIAL INFORMATION
1. Confidential Information shall mean any and all information which is marked confidential or is of a nature which should reasonably be expected to be held confidential regardless of whether it be oral or written, and any information or material which is proprietary to the Organization, whether or not owned or developed by the Organization, which is not generally known other than by the Organization, and which the Volunteer may obtain through any direct or indirect contact with Organization.
2. Confidential Information shall include all information provided by the Organization to the Volunteer or prepared by Volunteer for Organization in connection with the work performed by Volunteer such as, including without limitation: technical and non-technical data and analysis; plans, proposals or feasibility studies; financial information; information relating to actual or potential clients or beneficiaries; marketing information; and any information relating to the business or affairs of the Organization.
II. COVERED PARTIES
1. For purposes of this Agreement, the definitions of the Volunteer shall be deemed to include any representative or agents of such party. Volunteer shall be solely responsible for all actions and obligations of its representatives or agents as if they were the actions and obligations of that party.
III. NON-DISCLOSURE AND LIMITATITIONS OF USE OF THE CONFIDENTIAL INFORMATION
1. The Volunteer agrees that it shall use all the Confidential Information solely for purposes relating to the work performed for Organization, that all the Confidential Information will be kept strictly confidential and that the Volunteer shall not disclose any Confidential Information in any manner whatsoever, directly or indirectly, to any third party except as expressly permitted in this Agreement.
2. The Volunteer shall exercise, in good faith, the same degree of care in safeguarding the Confidential Information against any and all loss or other inadvertent disclosure as the Volunteer uses for its own confidential information of like importance.
3. In the event that Volunteer is requested or required (by oral question, interrogatories, requests for information or documents, subpoenas, civil investigation or similar process) to disclose any of the Confidential Information, Volunteer will provide Organization with prompt notice of such requests so that Organization, as applicable, may seek an appropriate protective order, or if appropriate, waive compliance with the provisions of this Agreement.
IV. OWNERSHIP OF THE CONFIDENTIAL INFORMATION
1. The Organization may terminate the Volunteer’s review of the Confidential Information at any time upon notice to the other party. At the time of such termination or the conclusion of the discussions between the parties, the Volunteer shall immediately cease the further use of any Confidential Information and return it to the Organization or handle the Confidential Information in any other way agreed upon by the parties.
2. No termination or return of the Confidential Information will affect any of Volunteer’s obligations under this Agreement, unless otherwise agreed upon by the parties.
V. REMEDIES
1. The Volunteer shall be responsible for any breach of this Agreement by the Volunteer. The Volunteer acknowledges and agrees that any disclosure of the Confidential Information except as provided in this Agreement may cause serious and irreparable damage to the Organization for which there may be no adequate remedy at law. Without limiting the Organization’s rights and remedies which are otherwise available, the Organization shall be entitled to equitable relief including, without limitation, an injunction, restraining order or specific performance for any breach of this Agreement by the Volunteer.
VI. INDEMNITY
1. Each party shall indemnify, defend and hold the other party harmless from and against any and all claims, losses, defenses, actions, causes of action, damages, costs or expenses (including reasonable attorney fees and any other costs) both direct and indirect, asserted, claimed or caused if and to the extent the same arises in whole or in part, directly or indirectly, from any breach of this Agreement by that party.
Retreat Waiver
(Required)
I agree to the retreat waiver
I, the undersigned attendee the (“Participant”) do hereby consent to participating in the D.R.I.V.E. Retreat (“DRIVE”), a project of The Mainstay Foundation (“Mainstay”).
I acknowledge that my participation in DRIVE may expose me to a variety of risks, including but not limited to, the possibility of injury or death. I grant the DRIVE Staff authority to obtain emergency medical treatment for me when deemed necessary. I agree to waive and release Mainstay, its employees and agents, from all claims, causes of action, grievances, and liabilities, both in law and equity, for damages that may arise as a result of my participation in DRIVE.
I acknowledge that I will travel by automobile or bus to the campsite. I agree to waive and release Mainstay, its employees and agents, from all claims, causes of action, grievances, and liabilities, both in law and equity, for damages that may arise as a result of my commute to and from the campsite.
I acknowledge that many pictures and/or videos will be taken throughout DRIVE and used for marketing and promotional purposes. I consent to being in the photographs and/or videos. My name/identification may be published.
Finally, I acknowledge that if I desires to leave the campsite for any reason before the scheduled departure, I will be responsible for arranging transportation and covering any associated costs.
I acknowledge and confirm that I have read this entire document prior to signing below.
Cell Phone Rule
(Required)
I agree to the cell phone rule
I/We, the participant(s), agree to the following:
• I promise I will take a break from my phone during this retreat and enjoy the beautiful scenery and fun activities.
• I promise I will not waste my time on my phone and remain active and healthy during the retreat.
• I promise I will not use my phone at the lake.
• I promise I will not take any pictures, video, etc. of any of the female participants who observe the Hijab without their headscarves on.
• I promise I will not take any pictures, video, etc. of any participant without their explicit consent.
• I promise I will not post any pictures, video, etc. on any social media outlet (Facebook, Instagram, Snapchat, etc.) without the explicit consent of everyone in the picture, video, etc.
I understand that violation of any of these rules will result in immediate expulsion from the camp.
I have read the above statements and agree to abide by these rules while participating at the DRIVE Retreat.
Total
Credit Card
(Required)
Page load link
Go to Top