Itikaf Application Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Personal Information Name *FirstLastEmail *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Start Date *I'tikaf Start DateEnd Date *I'tikaf End Date Emergency Information Name *FirstLastEmail *Phone * Health Information Please specify any Medical Condition or Allergies. Enter NONE if no conditions Medical Condition *Allergies *General Rules: Itikaf is for men only Minimum age requirement: 18 years Participants are responsible for arranging their own Suhoor and Iftar No food is allowed in the masjid area No visitors are allowed in the Itikaf area No group meetings or private study circles Un-Islamic conduct or any form of misconduct will not be acceptable Participants must keep the masjid area clean, including bathrooms and shower facilities Respect all fellow participants, regardless of age Only registered individuals will be allowed in the designated Itikaf area Completion of a form does not guarantee placement – spaces are limited Disclaimer: Islamic Center of East Brunswick (ICEB) 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 on our masjid at 402 New Brunswick Ave., East Brunswick, NJ 08816. By signing below, you agree to adhere to ICEB masjid policies and procedures, and will not hold ICEB Masjid and its entities liable for any suffering that may occur. Declaration *I declare that the information above is true and I agree to the rules and regulations stated above.Submit I'tikaf Request