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Impact #1

Registration Details

Name*
Email*
IMPORTANT: Please use a unique email address for each registration! Using the same email address for multiple registrations can result in being flagged as spam by our system.
Mailing Address*
Home Church*
Please select your home church.
Gender*
This week of Impact is only for grades 2-4.
Shirt Size*
Please specify the t-shirt category you wear below, and then your actual size in the next box that appears.

Liability Release Form

Parent/Guardian's Name*
Optional (not required).
Name on Policy*
The name of the individual on the insurance policy.
The relationship of the named insurance individual to the camper.
The contact number associated with the named insurance individual.
Alternative/Emergency Contact Name*
Put "N/A" if not applicable to camper.
Put "N/A" if not applicable to camper.
Put "N/A" if not applicable to camper.
Put "N/A" if not applicable to camper.
Put "N/A" if not applicable to camper.
Put "N/A" if not applicable to camper.
Clear Signature
Clear Signature

Payment Details

Administrator use only.
Credit/Debit Card*
This page is SSL encrypted for security. Your payment details are never stored or shared.
Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Expiration Date
 
This field is for validation purposes and should be left unchanged.

 
 

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