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Office - (903) 872-3664

Impactetx@gmail.com

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Summer Camp 2024
Registration

Which camp are you attending?

Student Information

Student First Name

Student Gender

Student Last Name

Date of Birth

Address

Parent Information

Parent First Name

Phone

Parent Last Name

Parent Email

Church Information

Which church do you attend?

Authorized Pick Up

Please enter up to two people authorized to pick up your student. If the parent/guardian listed above is one of them then their information must be entered below as well.

Authorized Pick-up #1

Authorized Pick-up #2

Driver's License/State ID

I understand only the persons listed above may pick up my student. NO EXCEPTIONS!

I understand that the ID listed above must be shown to pick up my student

Medical Information and Waiver

Emergency Contact

Insurance Provider

Insurance Policy No

Insurance Subscriber Name

Emergency Contact Phone

Insurance Phone No

Insurance Group No

Insurance Subscriber DOB

Allergies

List all food allergies

List all environmental allergies

List all medical allergies

Medications

List all medications

List all physical activities that your student cannot participate in

I understand all medications must be turned in to medical staff who will administer medications to my student

I give permission for medical staff to administer medication to my student as needed

Waivers and Releases

Camp Rules

Camp Waiver and Release Form

I have received the following documents and I agree to all terms....

Camp Rules

Camp Waiver and Release

Camp Activity Form

Photo Use and Release

Optional add on's

Add paintball?

Add orbeez?

T-Shirt?

Open a concessions tab?

Select Your Shirt Size

Concession tab amount

Registration Deposit

Camp Deposit (non-refundable, non-transferable) - $25

I agree to receive a Square invoice via SMS text for the remaining balance

Parent signature or Student signature if 18 or over

I agree to the above terms and conditions

Date signed

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Summer Camp 2024 Registration