Registration

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Thank you for attending an Impact Birthday Party! All birthday party guests must complete waiver before attending an Impact party. Current Impact families do not need to sign as they have already done so at class registration.

Event:

Start Date/Time:

End Date/Time:

Fee per Family:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Relation to Student
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	Grade Level:
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):
	Medications (Leave blank if NONE):
	Primary Doctor:

Questions/Options:


Date of Birthday Party*
Participant's Name*

Additional Information:

Release of Liability

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I've read the above and agree.

Video & Photo Waiver

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I've read the above and agree.

Enter your Full Name: