Impact Kids Intake/Consent Form • Impact Church

PLEASE CHOOSE FROM ONE OF THE FOLLOWING OPTIONS FOR EACH FAMILY MEMBER. PLEASE MAKE SURE TO FILL OUT PARENT INFORMATION AS WELL AS INFORMATION FOR EACH CHILD.

Please Choose From One of the Following Options *

Parent/Guardian (Primary Contact)

Parent/Guardian (Secondary Contact)

Child

First Name *

Last Name *

Phone Number *

Email Address *

Gender *

Date of Birth *

School Grade *

List any allergies your child has (leave blank if none)

Does your child have any special concerns we should know about?

If there are any custody concerns, please provide a brief description:

Guidance and Behavior Policy

Our goal is to create a safe, respectful, and nurturing environment for all children.

If a child’s behavior is disruptive or not following instructions, the teacher will guide them through appropriate redirection and correction.
If a child’s behavior becomes harmful or aggressive, we will contact the parent to come and pick them up.

All guidance and discipline will follow the Plan to Protect guidelines, ensuring that it is age-appropriate and suited to the situation (e.g., redirection, removal from an activity, or a brief time-out).

Photo Consent

I give Impact Church permission to photograph &/or film my child and use his or her picture/video for the church’s social media platforms including but not limited to Instagram, Facebook & Youtube, as well as the church’s website and marketing materials presently and in the future.

Parental/Guardian Consent

By typing in your name you are agreeing that you have read the guidance and behavior policy on this form. You agree to abide by the terms as stated above. You declare that the information on this form is correct and complete. *

Date *

Before clicking submit, click "add another person" to input information for each child you are checking into Impact Kids OR to add another parent/ guardian contact.