Mpact Registration

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email

Personal Information

Date of Birth

Shirt Size

Grade

Girl's Date of Salvation

Do you attend church?

Yes
No

Where do you attends church at

Father's Name

First

Last

Mother's Name

First

Last

Sibling's 1 name

First

Last

Sbling's 2 Name

First

Last

Sbling's 3 Name

First

Last

Sbling's 4 Name

First

Last

Mpact Group (Select one)

Emergency Medical Information

Family Doctor's Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Doctor's Phone

Is your child allergic to penicillin?

Yes
No

Date of last Tetanus shot (if known)

Medications - Please list

Other Allergies, Medical Problems and/or Learning Disabilities

Medical Permission

In 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.

Signature

Today's Date

Charter yearly cost

Price: $ 20.00

Additional siblings $5.00 each due at first meeting in September

Personal Information

Emergency Medical Information

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