Registration Form

The Impact Day Committee is excited to have you join our in-person wellness event on Saturday May 18, 2024. Impact Day is a day of learning how to better your mental, physical, and emotional self. We will have vendors with community resources and services as well as classes and workshops. See you soon!
Name*
Contact Number*
E-mail*
example@example.com
Zip Code*
Do you have any food allergies or restrictions?

Meat FreeDairy freePeanut allergyRestriction not listed, please input in the field belowNo restrictions
Other Restriction
On a scale from 1 to 5, (1 being the lowest, and 5 being the highest),how would you rate your overall health? (mentally, emotionally, socially, spiritually, and physically).*

12345
Will you be bringing a child(children) to the event?*

YesNo
Please list the total number of attendees that will be joining you.
What is at least one thing you are looking forward to during the event?
How did you hear about this event?

Delta Sigma ThetaNew Hope Baptist ChurchCBWPAAlpha Kappa AlphaSigma Gamma RhoSocial MediaFlyerA FriendEmailSchoolOther
I hereby give the Denver Alumnae Chapter of Delta Sigma Theta Sorority, Inc. (DAC) and their affiliates permission to take photographs and/or video/digital footage of me. This includes photographs and/or video/digital footage in which I may be involved with others for the purpose of promoting Health and Wellness, other activities of the DAC, redistribution, and marketing. I understand that this footage could also be broadcast as part of local, regional, and national newscasts, feature stories, and/or as part of publications. I hereby release and discharge the DAC, and/or any of their partner organizations and/or affiliates from any and all claims arising out of the use of the photos and video/digital footage.
Do you agree to the photo release statement above?

YesNo
Exercise and other fitness programs may result in injury. They include but are not limited to the risk of injury, aggravation of a pre-existing condition, or adverse effects of over-exertion such as muscle strain, abnormal blood pressure, fainting, disorders of heartbeat, and heart attack. Before beginning any exercise or nutrition program, please consult a physician or other health care professional for appropriate prescriptions and safety precautions to reduce the risk of injury. The instructions and advice presented are not intended as a substitute for medical consultation. The Denver Alumnae Chapter of Delta Sigma Theta Sorority, Inc., New Hope Baptist Church and its organization affiliates are not liable for any injuries that may occur during Impact Day.
Do you agree to the above physical activity release?

YesNo
Are you interested in joining our "Walking Challenge"?

Yes
Can we contact you in the future?

YesNo
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