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ImpAct Enrollment Form
Customer information for ImpAct Youth fitness classes.
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* Indicates required question
Email
*
Your email
Parent's Name
*
Your answer
Phone number
*
Your answer
Address
*
Your answer
Child's Name
*
Your answer
2nd Child's Name
Your answer
Child's Age and DOB
*
Your answer
2nd Child's Age and DOB
Your answer
List any health issues to be aware of.
Your answer
Youth Shirt Size
S
M
L
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I understand that ImpAct Youth Fitness is a voluntary program. Enrollment isn't complete until payment has been made.
*
Yes
Required
Periodically pictures are taken for promotional purposes only. Please let us know if you are alright with pictures or video of your child. Please check appropriate box.
*
Yes it is alright.
No pictures are to be taken.
A copy of your responses will be emailed to the address you provided.
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