IMPACT (2023-2024 School Year) and Teen Week Registration

Name of Teen

FAVORITE CANDY BAR :)

Important Medical Information such as ALLERGIES, Chronic Illness, or other condition

Birthdate

Grade Entering

7 8 9 10 11 12 New Graduate

Address

Can we communicate with your teen through their own e-mail address?

Yes No

Email of Teen

Name of Parent/s or Guardian

Email will be the PRIMARY source of communication we will have with your family. These emails will be related to IMPACT and will provide information you and your teen/s may need to know about weekly activites, dates IMPACT will not meet, special events and activites, and information about the things your teen/s are studying. If you prefer not to receive these emails, please remember that you may not have the most accurate information about what is happening on Wednesday evenings.

Yes No

Parent Email

This address will receive a confirmation email

Parent Email

This address will receive a confirmation email

We will never 'spam" or send you needless text messages. We will use a text communication method during weather-related closings and/or in the case of an emergency. If you desire not to receive text messages, We will do our best to respect that choice. Please indicate in Accept Conditions below.

Yes No

Mother's Cell Phone

Father's Cell Phone

Can we communicate with your teen on their own cell phone via text?

Yes No

Teen's Cell Phone

Teen Week

Will your teen be attending Teen Week 2023 (June 5-7)?

Yes No

T-Shirts Will be available to Earn or for Purchase for $8 each. What size do you wear?

Medical Permission

As the parent/guardian of the child(ren) named, I do hereby authorize treatment of the child(ren) named on this form in the event of a medical emergency that may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted ONLY after a reasonable effort has been made to reach me by phone at the number(s) listed above. I assume the responsibility of any cost connected with such treatment and hereby release Johnstown Independent Baptist Church, 7397 Johnstown-Alexandria Road, Johnstown, OH 43031, from any liability for any accident, injury, or costs that may occur. This release form is completed and accepted of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Yes No

Media Permission

JIBC periodically receives attention from local newspapers about our AWANA and/or IMPACT programs. We ourselves take pictures of children and activities to use on our Facebook page, website, or occasionally a printed flyer. We need a legal guardian’s permission to do these things and ask you to respond to this information. If you choose not to grant permission, this will in no way affect any child’s opportunity to participate in programs or events. So that we can honor your wishes, mark the box indicating your choice. Please call if you have questions or concerns at 740.967.7417.

Yes No

Transportation Permission

I do hereby authorize member van drivers of JIBC to transport my child(ren), listed above, to and from IMPACT ministries or activities. I release Johnstown Independent Baptist Church, 7397 Johnstown-Alexandria Rd., Johnstown, Ohio, from any liability for accident or injury incurred from transportation in our church van or member vans.

Yes No

IMPACT (2023-2024 School Year) and Teen Week Registration

Description

Please Fix the Following