Mpact Registration NameFirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneEmailShirt SizePersonal InformationDate of BirthGradeGirl's Date of SalvationDo you attend church?YesNoWhere do you attends church atFather's NameFirstLastMother's NameFirstLastSibling's 1 nameFirstLastSbling's 2 NameFirstLastSbling's 3 NameFirstLastSbling's 4 Name FirstLastMpact Group (Select one)Rainbows (Grades Pre K, Age 4-5)Daisies (Grade k)Prisms (Grades 1-2)Stars (Grades 3-6)Friends (Grades 7-12)Emergency Medical InformationFamily Doctor's NameFirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDoctor's PhoneIs your child allergic to penicillin?YesNoDate of last Tetanus shot (if known)Medications - Please listOther Allergies, Medical Problems and/or Learning DisabilitiesMedical PermissionClear SignatureIn case of emergency and I cannot be located, I authorize Mpact to secure emergency medical care for my child. I hereby give the Mpact Staff permission to render first aid, take my child to the hospital in an emergency, and permission for a physician to give or order any necessary treatment. SignatureClear SignatureToday's DateCharter yearly cost Price: $ 20.00CommentSubmit Share this:TwitterFacebookLike this:Like Loading...