Impact After-School Registration


Please complete all information below and click the 'Submit' button.
If you have any questions, Call OR Text to: 304.933.1234.

Student Name:
Parent/Legal Guardian Name:
Cell Phone(s):
Home Phone:
Parent/Guardian Employer:
Parent/Guardian Employer Phone:
Emergency Contact & Phone:
School Student Attends:
Grade:  Age:  
Release my child as a: Activity Bus Rider
Mountaineer Middle (MM) Students:
 YES! I am granting permission for this MMS Student to be released from the school to the IMPACT bus for the transport to WIMS to attend IMPACT. I understand that the program will not end until 4:30 and I will specify below how I want my child dismissed, either as a walker or as a rider on the IMPACT activity bus.  I understand that if I choose for my child to be released as a walker, that he/she will be dismissed at 4:30 from WIMS on Lee Avenue and will be transported back to MMS arriving at 5:00 and released for the parents to pick up.

Electronic Signature
 YES! I give permission for the above-named student to attend IMPACT and/or any of its future events and I fully understand and agree that this permission shall remain in effect until canceled in writing by the undersigned parent/guardian, provided that a thirty days notice is given in order to affect said cancelation of my consent.  I understand that affixing my name here and submitting this form will constitute my granting permission as if I signed in person. I have fully read all the content provided by impact, whether in written, oral, or electronic / website form, and agree to grant permission for this student to participate. I agree to supply true and accurate information within the form.  I understand that every reasonable effort will be made to provide a safe and secure environment at all Impact-Sponsored events and activities, but accidents can happen as well as things beyond the control of impact or any agent acting on its behalf.  Nevertheless, I do hereby agree to hold Impact, or any agents thereof, harmless.  I accept full responsibility for my student and their actions.  I further understand that no cell phones or electronics are permitted at any impact sponsored activity or event and that all persons are subject to search and screening at the point of entry, all of which i hereby do give my consent and permission.
Parent/Legal Guardian Initials: Signed & Agreed by: