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Contact Us
MUMINEEN INFORMATION FORM
Please fill the form below
1.
NAME
2.
ITS
3.
AGE
4.
JAMIAT
--- Select Jamiat ---
AHEMDABAD
BARWANI
BHAVNAGAR
BHOPAL
BURHANPUR
CALCUTTA
DOHAD
EAST AFRICA
FAR EAST
INDIAN OCEAN
INDORE
JAMNAGAR
KHALEEJ
KUWAIT
MADRAS
MAROL
MUMBAI
MUMBRA
NASHIK
NAGPUR
PAKISTAN
POONA
RAJKOT
RAMPURA
SURAT
TAHERABAD
UJJAIN
UK
USA
YEMEN
5.
MAUZE
6.
GENETIC CONDITIONS
Check all that apply.
AUTISM
CEREBRAL PALSY
DOWN SYNDROME
FRAGILE X SYNDROME
PRADER - WILLI SYNDROME
NON - VERBAL LEARNING DISORDER DYSLEXIA
APERT SYNDROME
ADHD
DEVELOPMENTAL DELAY
NONE
OTHER
7.
PHYSICAL CONDITIONS
Check all that apply.
VISUAL IMPAIRMENT
HEARING IMPAIRMENT
LOCOMOTOR DISABILITY
AMPUTATION
NEUROLOGICAL ISSUES
SENSORY DISABILITIES
DWARFISM
NONE
OTHER
8.
DO YOU REQUIRE SOMEONE TO ASSIST YOU DURING MAWAQIT / EVENTS?
Yes
No
9.
[1] CARE GIVER'S NAME [PRIORITY]
The person who will be tagged with you and will accompany you in all miqaat.
10.
[1] CARE GIVER'S ITS [PRIORITY]
11.
[1] CARE GIVER'S RELATION [PRIORITY]
12.
[2] CARE GIVER'S NAME
13.
[2] CARE GIVER'S ITS
14.
[2] CARE GIVER'S RELATION
15.
[3] CARE GIVER'S NAME
16.
[3] CARE GIVER'S ITS
17.
[3] CARE GIVER'S RELATION
18.
WHAT ARE THE BASIC NEEDS AND REQUIREMENTS SO THAT WE CAN FACILITATE YOU WELL?
19.
I ACCEPT TO SHARE THIS INFORMATION WITH THE UMOOR SEHHAT TEAM TO BETTER FACILITATE REQUIREMENTS.
--- Select ---
Yes
No
Submit