Enrollment Form

بِسْمِ اللهِ الرَّحْمٰنِ الرَّحِيْمِ

In the Name of Allah—the Most Compassionate, Most Merciful.
Thank you for your interest in participating in the Funeral Aid Program.

To enroll into the program, the following information will be required:

A. Participant name, phone number, email address, date of birth, and address.

B. If Applicable, Spouse and Children names and date of births, and spouse's phone number and email address.

C. At least one emergency contact name and phone number.

D. Bank Account Details such as institution number, transit number, and account number, which can be found on your cheque (as shown below):

The digits at the bottom of your cheque are described below.

1. The first set of digits are a cheque number: not required
2. The second set of digits (5 digits) are the Branch number: required
3. The third set of digits (3 digits) are the Institution number: required
4. The last set of digits (various lengths) are the Account number: required

ENROLLMENT FORM
Enrollment Type:*

SelfFamily
Family Members to be Enrolled:

SpouseDependent Children
Total # of Dependent Children
Unmarried Children under the age of 25 only
TOTAL ADDITIONAL FAMILY MEMBERS
TOTAL PARTICIPATION FEES*
Total Participation Fees:

${participationFees}.00
OFFICE USE ONLY
Enrollment Status
Payment Method:
Payment Reference #
Payment Date:

YearMonthDay
Date
Internal Notes
Certificate Number
Effective Date:
Certificate Issue Date

YearMonthDay
Send Certificate
Skip to the last page?

NoYes
Authorized Person's Signature

Clear
Authorized Person's Name
Authorized Person's Title

PARTICIPANT/PRIMARY CONTACT DETAILS
Participant's Name*

First NameLast Name
Participant's Email*

Confirmation Emailexample@example.com
Participant's Home / Cell Phone*
Participant's Alternate Phone
Participant's Date of Birth*

YearMonthDay
Participant's Gender*

MaleFemale
Unique Name and DOB Check*
Participant's Address*

Street Address

Street Address Line 2

CityProvince / State

Postal / Zip CodeCountry
Are you or any member of your family wish to be contacted to volunteer?*

YesNo

ADDITIONAL FAMILY MEMBERS
SPOUSE DETAILS
Spouse Name

First NameLast Name
Spouse Email
example@example.com
Spouse Home / Cell Phone
Spouse Alternate Phone
Spouse Date of Birth

YearMonthDay
Spouse Gender

FemaleMale
Is the Spouse Address same as the Participant / Primary Contact?

YesNo
If NO, please provide Spouse Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DEPENDENT/UNMARRIED CHILDREN

(under the age of 25 years old only)
Child 1 Name

First NameLast Name
Child 1 Date of Birth

YearMonthDay
Child 2 Name

First NameLast Name
Child 2 Date of Birth

YearMonthDay
Child 3 Name

First NameLast Name
Child 3 Date of Birth

YearMonthDay
Child 4 Name

First NameLast Name
Child 4 Date of Birth

YearMonthDay
Child 5 Name

First NameLast Name
Child 5 Date of Birth*

YearMonthDay
Child 6 Name

First NameLast Name
Child 6 Date of Birth*

YearMonthDay
Child 7 Name

First NameLast Name
Child 7 Date of Birth*

YearMonthDay
Child 8 Name

First NameLast Name
Child 8 Date of Birth*

YearMonthDay

EMERGENCY CONTACT DETAILS
Contact 1 Name*

First NameLast Name
Contact 1 Phone*
The Contact 1 is for:*

Participant OnlySpouse OnlyBoth
Contact 2 Name

First NameLast Name
Contact 2 Phone
The Contact 2 is for:

Participant OnlySpouse OnlyBoth

TERMS AND CONDITIONS
1. Definitions

1.1 “Burial Location” means Vedder View Gardens Cemetery located at 44675 Watson Rd, Chilliwack, British Columbia V2R 2Y6, CANADA.

1.2 “Coverage Area” means any location in the Province of British Columbia where the Service Provider provides funeral and burial services to the Sunni Muslim community.

1.3 “Dependent” means an unmarried child who is entirely dependent on the Participant for maintenance and support, AND who is:

a. under 25 years of age, or

b. physically or mentally incapable of self-support.

1.4 “Family” means Spouse and Dependent children of the Participant.

1.5 “Funeral Costs” means the cost of funeral and burial of the deceased at the Burial Location set forth by the MFAS.

1.6 “MFAS” means MFAS - Muslim Funeral Aid Services.

1.7 “Participant” means the person named in Section A of the Enrollment Form.

1.8 “Service Provider” means THE BRITISH COLUMBIA MUSLIM ASSOCIATION or any other Islamic organization providing funeral and burial services to the Sunni Muslim community.

1.9 “Spouse” means the person who is married to the Participant.

2. Coverage

2.1 The Participant and his or her Additional Family Members (if applicable) must be of the Sunni Muslim faith in order to enroll into the funeral aid program.

2.2 The coverage for the Participant and for his or her Additional Family Members (if applicable) shall only become effective after 90 days from the date the total Participation Fees are received by the MFAS (“Effective Date”).

2.3 The deceased’s body must be physically located within the Coverage Area and shall be buried at the nearest burial site serviced by the Service Provider, subject to the maximum cost set forth under paragraph 2.4. Any cost above the maximum threshold shall be the responsibility of the Participant, his or her Additional Family Members, heirs, executors, or trustees.

2.4 MFAS will cover the Funeral Costs for the deceased up to the cost of funeral and burial at the Burial Location.

2.5 If the family members, heirs, executors, or trustees of the deceased wish to bury the deceased at a burial site within the Coverage Area which is higher in costs than the Burial Location, any difference in the cost of funeral, transportation, and burial at a different location within the Coverage Area shall be the responsibility of the Participant, his or her Additional Family Members, heirs, executors, or trustees.

2.6 MFAS will not reimburse, pay, or be responsible for the transportation, funeral, or burial costs of the deceased if the deceased’s body is located outside of the Coverage Area.

3. Participation Fees

3.1 The Participation Fees collected from the Participants will be held in a non-interest-bearing pooled general trust account held at a financial institution in Canada under the name of MFAS (“Pooled Trust Account”).

3.2 MFAS reserves the right to change the Participation Fees at anytime without notice.

4. Withdrawals from the Pooled Trust Account and Participant’s Share of Funeral Costs

4.1 The Participant irrevocably authorizes MFAS to deduct $25.00 for operating costs from the Pooled Trust Account on or after the Effective Date of the coverage.

4.2 Upon the death of any Participant and/or any of his or her Additional Family Members covered under the coverage, or subject to availability and upon the death of a non-participant requiring funeral aid services from the coverage(s) donated, MFAS shall pay the Funeral Costs directly to the Service Provider, subject to these terms and conditions. It is the responsibility of the deceased's heirs, executors, or trustees to arrange for the funeral and burial of the deceased with the Service Provider.

4.3 The Participant irrevocably authorizes MFAS to withdraw funds from the Pooled Trust Account to cover the Funeral Costs of any Participants and/or their Additional Family Members.

4.4 The Funeral Costs will be equally divided among the “Participants” and the “Total Number of Coverage(s) Donation Pledged” (“Share of the Funeral Costs”). Each Participant shall be responsible for paying MFAS his or her Share of the Funeral Costs upon the death of a participant, his or Additional Family members, or non-participant requiring funeral aid services from the coverage(s) donated (“Participant’s Share”).

4.5 A written Notice to Pay shall be sent by the MFAS to the Participant’s email address at least 72 hours prior to the date of withdrawal of the Participant’s Share of Funeral Costs that will be withdrawn from the Participant’s account, pursuant to the Pre-Authorized Debit (PAD) Agreement. It is the responsibility of the Participant to ensure that he or she has sufficient funds in his or her account to pay for his or her share of the Funeral Costs. MFAS is not responsible for any charges incurred by the Participant due to insufficient funds.

4.6 Participant’s Share of Funeral Costs are non-refundable.

5. Cancellation, Termination, and Refunds

5.1 The coverage for the Participant and for his or her Additional Family Members (if applicable) terminates after 120 days of the death of the Participant. The Spouse of the Participant may enroll into the funeral aid program and become a Participant by filing out a new enrollment form and paying the applicable participation fees.

5.2 The Participant may cancel the coverage anytime before the Effective Date by giving written Notice of Cancellation to the MFAS.

5.3 After the Effective Date of the coverage, 30 days written Notice of Cancellation is required to cancel the coverage.

5.4 Upon receiving the Notice of Cancellation from the Participant, the coverage for the Participant and for his or her Additional Family Members (if applicable) shall be cancelled immediately and MFAS shall refund to the Participant after 30 days of receiving the Notice of Cancellation:

a. 100% of the Participation Fees, if the Notice of Cancellation is received before the Effective date, or

b. Participation Fees less $25.00, if the Notice of Cancellation is received after the Effective date.

5.5 The Participation Fees becomes non-refundable once a funeral aid service has been provided to the Participant and/or to any of his or her Additional Family Members.

5.6 If for any reason the MFAS is not in receipt of the Participant’s Share of the Funeral Costs within 90 days of the date of Notice to Pay as described under paragraphs 4.2 and 4.5, the coverage for the Participant and for his or her Additional Family Members (if applicable) shall be cancelled, and the Participation Fees paid by the Participant shall be forfeited by the MFAS without any further notice to the Participant.

5.7 Coverage for the Dependent terminates on his or her 25th birthday or upon marriage of the Dependent, whichever occurs first. In case of the physically or mentally incapable Dependent, the coverage terminates upon marriage of the Dependent.

6. General

6.1 MFAS reserves the right to change, any, all, or part of the terms and conditions from time to time. A Notice of such change will be sent to the Participant’s email address. If a Participant does not agree to the new terms and conditions, he or she may exercise his or her right under these Terms and Conditions to cancel his or her coverage within 15 days. If a Notice of Cancellation is not received by the MFAS within 15 days of the Notice of Change of Terms and Conditions, the new Terms and Conditions deemed to have been accepted by the Participant.

6.2 It is the responsibility of the Participant to keep his or her information up to date. On an annual basis, the MFAS may send request to Participant via e-mail to verify contact information. It is the responsibility of the Participant to monitor his or her email address, including the spam folder. If after three attempts the MFAS does not receive a response from the Participant, the coverage for the Participant and/or his Additional Family Members will be cancelled, and the Participation Fees will become non-refundable and transferred to the operating account, without any further notice.

6.3 The Participant consents to receiving certain electronic communications from MFAS.

6.4 The Participant agrees that any notices, agreements, disclosures, or other communications that MFAS send to the Participant electronically will satisfy any legal communication requirements, including that those communications be in writing.

6.5 The Participant authorizes and consents to the use, release and exchange of information provided in the Enrollment Form and any schedules therein between the organization, third party service providers and the financial institution(s) to be used solely in connection with the administration of the funeral aid program.

***Guildford Islamic Cultural Center is a community partner of the MFAS – Muslim Funeral Aid Services.
DECLARATION:*

BY ELECTRONICALLY SIGNING THIS FORM, I DECLARE THAT: (a) the information contained in this form is true, correct, and to the best of my knowledge (b) the dependent children listed in this form are financially dependent on me, are unmarried, and under the age of 25 years old; and (c) I have read, understood, and agree to the Terms and Conditions as set forth by the MFAS - Muslim Funeral Aid Services. Falsification of any information provided by the Participant may result in denial of coverage by the MFAS.
Participant's Signature*

Clear

PRE-AUTHORIZED DEBIT (PAD) AGREEMENT
1. I authorize MFAS – Muslim Funeral Aid Services to withdraw a one-time payment for the Total Participation Fees of ${participationFees}.00.

2. I authorize MFAS – Muslim Funeral Aid Services to begin withdrawals of the Participant’s Share as per the Terms and Conditions set forth by the MFAS – Muslim Funeral Aid Services, each time upon the death of a participant, his or her additional family members, or non-participant requiring funeral aid services from the coverage(s) donated. A 72-hour notice will be sent to the Participant’s e-mail address prior to the withdrawal of the Participant’s Share.

Please ensure your Financial Institution is advised in advance of the above payments.

3. I acknowledge that any NSF fees will be my responsibility if payment is declined for any reason.

4. I will notify MFAS – Muslim Funeral Aid Services in writing if I move the account from one bank or branch to another, or if there are any other changes in the account.

5. I may revoke this authorization at any time, subject to providing notice to MFAS – Muslim Funeral Aid Services. I understand that if I cancel this authorization, it does not mean that my contract obligations to the MFAS – Muslim Funeral Aid Services are ended. For more information on my right to cancel a PAD agreement or obtain a sample cancellation form, I may visit: www.cdnpay.ca.

6. I am authorized to sign on behalf of the above account.

I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca. ***Guildford Islamic Cultural Center is a community partner of the MFAS – Muslim Funeral Adis Services.
PAD AUTHORIZATION:*

BY ELECTRONICALLY SIGNING THIS AGREEMENT, I agree and authorize MFAS - Muslim Funeral Aid Services to withdraw the funds as indicated above from my bank account.
Account Holder's Signature*

Clear
Should be Empty:

بِسْمِ اللهِ الرَّحْمٰنِ الرَّحِيْمِ

Total Participation Fees:

${participationFees}.00

OFFICE USE ONLY

PARTICIPANT/PRIMARY CONTACT DETAILS

ADDITIONAL FAMILY MEMBERS

SPOUSE DETAILS

DEPENDENT/UNMARRIED CHILDREN

EMERGENCY CONTACT DETAILS

TERMS AND CONDITIONS

1. Definitions

2. Coverage

3. Participation Fees

4. Withdrawals from the Pooled Trust Account and Participant’s Share of Funeral Costs

5. Cancellation, Termination, and Refunds

6. General

PRE-AUTHORIZED DEBIT (PAD) AGREEMENT