Total Impact Education 2025

Total Impact Education Registration

All students must submit the registration form with health and emergency contact information. A non-refundable $25 membership fee is due with the registration. A form must be filled out for each child. (* Required field)

Student Name *

Parent Name *

Street Address *

City *

City

State *

Please provide a valid state.

Zip Code*

Zip code .

Parent Phone Number *

Parent Phone Number (Other)

Parent email address *

Student Birthdate *

Days Attending *
Monday
Tuesday
Wednesday
Thursday
Friday

What church, if any, do you attend regularly?

Zip code .

Special Health Concerns: (allergies, medications, etc.) *

Primary Care Information

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Insurance Information

Insurance Provider *

Insurance Policy No *

Insurance Phone *

Subscriber's Name *

Emergency Contact Information

Please list the names of any and all possible persons to whom we are allowed to release your child, if you are not available. Contacts MUST PROVIDE A PICTURE ID in order to pick up your child. By submitting this information, you give us the permission to share health information about your child with the people listed as emergency contacts.

Contact 01

Name *

Phone Number *

Relationship to Child *

Contact 02

Name *

Phone Number *

Relationship to Child *

Contact 03

Name *

Phone Number *

Relationship to Child *

By typing your name and date for the following statements you are giving your legal consent:

I hereby give permission to Total Impact Education to secure emergency medical and/or dental treatment and to provide emergency transportation for the above named child while in care.

I give permission for the image of my child to be taken in photograph or video, and to be used by Total Impact Education.

Signature *

Date *