Impact Summer Camp Form

Please fill out the form below if you or your student is interested in attending Impact Fall Retreat on Nov. 18-19th

Student's First Name

Student's Last Name

Birthdate

Age

Current Grade

Gender
Male
Female

Parent/Guardian's First Name

Parent/Guardian's Last Name

Parent/Guardian's Email

Parent/Guardian's Phone

Address Line 1

Address Line 2

Country

City

State

Zip/Postal Code

List any food or other allergies, as well as any physical, emotional, or mental limitations.