Impact Student Registration

Impact Student Registration
Hello! We here at Impact are so excited to get to know your teen and to partner with you to help them through what are some crazy years in Middle School and High School.

The form below helps us get to know you and your teen a little bit, and also is the waiver we have for the 2020/2021 school year (August 2020 - July 2021). It covers all the events we do (unless a place we go to has their own waiver form i.e. Skyzone).
Youth Information
How many students are you registering?
Student's Name

First NameLast Name
Grade
E-mail
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Gender
Student's Name

First NameLast Name
Grade
E-mail
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Gender
Student's Name

First NameLast Name
Grade
E-mail
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Gender
Student's Name

First NameLast Name
Grade
E-mail
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Gender
Student's Name

First NameLast Name
Grade
E-mail
Phone Number

Area CodePhone Number
Birthdate

MonthDayYear
Gender
Does your child have any medical conditions we should be aware of? (Allergies, asthma, etc.)
If yes, please explain.
Do you have any special concerns you would like us to be aware of?
If yes, please explain.
Parent/Guardian Information
Parent/Guardian #1
Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2
Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Would you like to receive emails for updates and events?
Which Parent/Guardian would like to receive updates and events?
Service Opportunities

By signing up you are not committing to every week, just to help out here and there.
I would consider serving Impact in the following areas. Please contact me with more information.
Other
Medical Release
I give permission for my child to participate in all aspects of Youth Ministries both on and off site. I understand that every effort will be made to contact me if my child needs emergency medical treatment. I authorize Branchline Church staff and youth ministry volunteers to secure any medical or emergency treatments deemed necessary for my child. My insurance company or I will pay for any medical treatment if costs are incurred.
Photograph & Video Release Form
My student's work and image (including video) can be placed on Branchline Church approved websites. These may be taken during events, regular youth group nights, service sites, trips, or other special events. In some instances your child may be identified by name as well. If you do not want your student's image placed on Branchline Church approved websites or other related forms of media, please indicate that in the box below instead of signing your name.
Should be Empty:

Impact Student Registration

Youth Information

Parent/Guardian Information

Service Opportunities

Medical Release

Photograph & Video Release Form