Impact Center Check-in

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Please fill out this form in its entirety. After filling out the form, you will receive a number by text. This number will be the number you use to pick up your child, and if the number appears on the screen, please meet a member of the youth & young adult ministry downstairs in the impact center.

Parents Name *

Phone Number (You will be texted a number if we need you. You will see a number on the screen or receive a text). *

Youth Name *

Age *

Todays Date *

YYYY

Are you a visitor? *

Yes

Please list any allergies *

Is your child currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Please check all that apply. *

Fever

Cough

Shortness of breath or difficulty breathing

Sore throat

None above

Required

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