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.

Parent/Guardian (Primary Contact)

Parent/Guardian (Secondary Contact)

Child

First Name *

Last Name *

Email Address *

Phone Number *

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? *

Yes

Please provide a brief description.

Custody Issues? *

Yes

If 'Yes' please explain

DISIPLINE POLICY

If there is behaviour that is disobedient or disrespectful, the child will be subject to the *disciplinary action of the teacher.
If there is behaviour that is harmful or aggressive, the parent will be called to come to pick up the child.

*Discipline will be in accordance with the Plan to Protect guidelines and will be age-appropriate and in context to the behavioural issue. (ie. Removal from the activity, time-out, etc.)

PHOTO CONSENT

I give Impact Church – Kingston 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.

Yes

PARENTAL/GUARDIAN CONSENT

By typing in your name you are agreeing that you have read the discipline 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.