Impact XP Esports Development Registration & Consent
Complete one form per child to register them and provide parent/guardian consent for participation and program communications.
Student Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
School
*
Team or Partner Site
*
Please Select
New Avenue Inc
Dellwood Rec
Gamers Island
Young Life
Other
T-shirt Size
*
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Adult 2XL
Adult 3XL
Other
Games Interested In
*
Madden 27
Tekken
Marvel Rivals
NBA 2K
Gaming Experience
Beginner
Casual player
Experienced player
Previously competed in esports
Access to Gaming Equipment for Practice
Yes
No
Sometimes / limited access
Not sure
Parent or guardian information
Parent or guardian full name
*
First Name
Middle Name
Last Name
Relationship to student
*
Please Select
Mother
Father
Guardian
Grandparent
Aunt
Uncle
Sibling
Other
Email address
*
example@example.com
Primary phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Emergency contact name
*
First Name
Middle Name
Last Name
Emergency contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Consent
Acknowledgments
*
I give permission for my child to participate in Impact XP activities, including supervised esports practices, development lessons, and scheduled competitions, and understand that final schedules and locations will be communicated to registered families.
My child will follow the program code of conduct, including good sportsmanship, respect for participants and staff, and proper use of gaming equipment, and I understand serious or repeated violations may affect participation.
I authorize New Avenue Inc. and authorized Impact XP staff to contact me using the information provided about my child's participation, scheduling, and program-related matters.
I understand that I am responsible for arranging my child's transportation to and from practices and competitions unless a separate transportation arrangement is confirmed in writing.
Photo and video permission
Yes, I permit New Avenue Inc. to use photos or videos of my child from Impact XP activities for program promotion and reporting
No, I do not permit promotional use of my child's image or video
Parent/guardian electronic signature
*
Date signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Form
Submit Form
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