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.

Insurance Information

If no insurance, please enter "N/A" in the Company and leave the remaining fields blank

Medication Authorization

I authorize IMPACT Staff to give any of the following medications to my child upon need (please check all that apply):

IMPACT Guidelines

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.
  1. All participants are to attend all sessions of IMPACT.
  2. IMPACT participants are not to leave the campus during IMPACT hours unless specifically signed out in IMPACT Central
  3. 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.
  4. TV’s, laser pointers, video games, MP3 players, computers etc. are not permitted. These items can easily be lost or stolen.
  5. Cell phones are not to be used in classes, devotionals and sessions in Allen Arena.
  6. 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.
  7. 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.
  8. Dress Code - Guys: Shirts – No wife-beaters, cut-off’s, or tanks with the wide-open armholes.
  9. 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.
  10. 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.
  11. Skateboards, roller blades, bicycles, and scooters are permitted only with proper safety equipment (helmet, kneepads and elbow pads) in designated areas.
  12. Conduct yourself in such a way that it would be best for all if everyone behaved as you do.

ACKNOWLEDGMENT OF RISK, RELEASE, AND MEDICAL AUTHORIZATION

IN CONSIDERATION of my child being permitted to participate in IMPACT at or with Lipscomb University from June 21, 2021 through June 23, 2021, I, the undersigned parent/guardian, in full recognition and appreciation of the dangers and hazards inherent in participating in such activity, the hazards inherent in transportation to and from any destination, the hazards inherent with this activity and in the circumstances to which my child may be exposed during his/her participation in the activity, do hereby agree to assume full responsibility for any risk of loss, damage or injury, including death, which may result from my child’s participation in the activity or any independent activities undertaken as a part thereof; and

FURTHER, I do for myself and my child’s personal representative(s), heirs and assigns, hereby agree to defend, hold harmless, indemnify, release, forever discharge and covenant not to sue the activity sponsor(s), Lipscomb University and all its trustees, officers, agents and employees from and against any and all losses, damages, claims, demands and actions, including reasonable attorneys’ fees, arising out of or related to any loss, damage or injury, including death, which may result from my child’s participation in such activity, and while traveling to or from the destination of the activity, whether caused by the negligence of Lipscomb University or any of its trustees, officers, agents or employees or otherwise; and

FURTHER, in order that my child may receive necessary medical treatment in the event of injury or illness during participation in such activity, I hereby authorize the activity sponsor(s), school officials and their designee(s) to administer and/or obtain appropriate treatment in the event of such illness or injury and I hereby agree to defend, hold harmless, indemnify, release, forever discharge and covenant not to sue the activity sponsor(s), Lipscomb University and all its trustees, officers, agents and employees from and against any and all losses, damages, claims, demands and actions, including reasonable attorneys’ fees, as a result of the exercise of the authority granted herein; and

FURTHER, I understand and acknowledge that Lipscomb University has established rules and regulations pertaining to conduct, behavior and activities of students by which I must abide during participation in such activity, and I agree to abide by all such applicable rules and regulations at all times during my participation in the activity.

I have read and understood this Acknowledgement of Risk, Release and Medical Authorization, am at least eighteen (18) years of age and fully competent and execute the same as my own free will.

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