IMPACT REGISTRATION FORM

A non-refundable $35/family registration fee is required upon completion of registration form. 

Also, if there is more than one child within the immediate family attending IMPACT, the cost for the first child is $150, the cost for the second child is $150, and the cost for each additional child is $75.

There is also a $10/child uniform t-shirt fee.

 

PLEASE READ all the information on this form before filling it out.

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Please place a check after the session(s) your child(ren) plans to attend:
Session:

Emergency Contacts

You or someone listed below must sign your child out each afternoon

YOUR CHILD WILL NOT BE ALLOWED TO GO WITH ANYONE WHO IS NOT ON THIS LIST. PHOTO ID is required for pickup.

Health Information

Does your child have allergies?
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Does your child have diabetes, epilepsy, earaches, asthma, headaches, chronic stomach aches, or other?
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Is your child on medication?
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Is your child allowed to have "over the counter" medication, if needed?
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NOTE:

All medication MUST be brought in original containers with original labels and given to the nurse at registration.

Rules for acceptance in the P.E. Wellness program are the same for everyone without regard to race, color, national origin, or gender.

Cancellations: Please notify us immediately so that a student on the waiting list can be contacted

PARENT MEDICAL AND LIABILITY RELEASE STATEMENT

  • I understand that in the event medical intervention is needed, every attempt will be make to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the physician or dentist selected by the IMPACT director, camp nurse, or ministry director to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

  • I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Bancroft Gospel Ministry through its accident policy will be used as a back up for what my family's insurance does not cover.

  • I understand all reasonable safety precautions will be taken at all times by Bancroft Gospel Ministry and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Bancroft Gospel Ministry, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries, incurred by the subject on this form.

  • I understand that Bancroft Gospel Ministry reserves the right to discipline or dismiss my child from IMPACT with forfeiture of fees if he/she is non-cooperative or non-compliant.

  • I further agree to indemnify and hold Bancroft Gospel Ministry harmless against any and all costs, damages, and expenses which may be incurred by them as a result of any claim I may make, actions I take against the camp, or lawsuits I may file against them.

  • I give permission for my child's picture to be used in future IMPACT publications, promotional videos and/or on the internet or social media.

By typing my name, I agree with the above Parent Medical and Liability Release Statement

By clicking the "Submit Registration/Pay Fee" button, you will be required to pay the $35/Family Registration Fee. Balance payments and Uniform T-shirt payments can be submitted by clicking the

"Make Payments" button on the IMPACT page.

141 Bancroft Private Dr., Kingsport, TN 37660

423-288-4532