IMPACT Attendee Management
Register a new IMPACT Attendee for
West Side - Russellville
Note: This is a replacement for the paper-based IMPACT Registration/Application form. No paper-based forms will be accepted this year.
Group Chaperone / Adult
Chaperone Child (not camper)
Class Teacher @ IMPACT
First Year at IMPACT?
Contact Email (for form questions)
Date of Birth (YYYY-MM-DD)
Grade (just completed)
Parent/Guardian First Name
Parent/Guardian Last Name
Address Line 1
Address Line 2
District of Columbia
Emergency Contact #1 Name
Emergency Contact #1 Phone (XXX-XXX-XXXX)
Emergency Contact #2 Name (optional)
Emergency Contact #2 Phone (XXX-XXX-XXXX)
If no insurance, please enter "N/A" in the Company and leave the remaining fields blank
Name of Insurance Company
Conditions pertinent to care
Allergies or Medications taken regularly
I authorize IMPACT Staff to give any of the following medications to my child upon need (please check all that apply):
Decongestant (ex. Sudafed)
Antacid (ex. Tums)
Acetaminophen (ex. Tylenol)
NONE of the above
I agree to follow all guidelines and requirements of Impact and will participate and cooperate in all its activities. I also understand that my/my child's bags and luggage may be inspected at check-in and my/my child's room may be searched at any time.
Campers are to be in their dormitories by 11:00 p.m. each night unless otherwise instructed by the IMPACT staff.
All participants are to attend all sessions of IMPACT.
IMPACT participants are not to leave the campus unless specifically signed out in IMPACT Central
Drugs, tobacco, alcohol, fireworks, and all types of weapons are not permitted on the Lipscomb campus. Your counselor should be notified of any prescription drugs you are taking.
TV’s, laser pointers, video games, MP3 players, computers etc. are not permitted. These items can easily be lost or stolen.
Cell phones are not to be used in classes, devotionals and sessions in Allen Arena.
Each dorm room is to be left clean by 7:30 each morning.
Report illnesses to a counselor or staff member as soon as possible. A nurse is on duty in the Health Center from 10:00 a.m. until 7:00 p.m.
Your room key must be returned to the front desk of your dorm before you leave for home. Your $20 key/clean room deposit will then be returned after your counselor inspects your room.
Dress Code - Girls: Modest, high-necked shirts. If sleeveless, the band/straps should be more than one-inch wide and with no bra straps showing. When you raise your arms you shouldn’t be able to see your stomach. When you bend down, you shouldn’t be able to see your underwear.
Dress Code - Guys: Shirts – No wife-beaters, cut-off’s, or tanks with the wide-open armholes.
Dress Code - Everyone: Girls and guys are expected to wear long shorts to follow Lipscomb’s dress code. We recognize that it’s difficult for some girls to find longer shorts. So, here’s the compromise: Shorts must be modest and come at least to mid thigh. We should not be able to see your underwear at any time—from the top or the bottom.
IMPACT officials reserve the right to remove any camper from the campus for disorderly conduct. No refund will be given in such a case. Any transportation costs are the responsibility of the camper and/or parent or legal guardian.
Skateboards, roller blades, bicycles, and scooters are permitted only with proper safety equipment (helmet, kneepads and elbow pads) in designated areas.
Conduct yourself in such a way that it would be best for all if everyone behaved as you do.
Medical and Liability Release
I hereby authorize my group’s chaperones, the director of IMPACT, Lipscomb University medical personnel or their designees to make any emergency healthcare decisions and to authorize or arrange for emergency medical treatment, if necessary, with any hospital, physician or other healthcare provider which shall be deemed necessary under the circumstances, according to his/her best judgment and to give the medications indicated on this page as deemed medically needed to my son/daughter.
I hereby release Lipscomb University, its trustees, officers, employees, agents (the “Releasees”), from any and all liability for sickness, accidents or injuries of any nature or cause whatsoever to my child or me, other than due to gross negligence or intentional fault of the Releasees, while attending, traveling to or from IMPACT.
Using your mouse or touch screen, please sign above
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