PROGRAM
APPLICATION

Program of Interest

Unique

Grown Folks Talking

Man Up

Youth First name

Youth Last name

Parent/Guardian Full Name

Date of Birth

Month

Day

Year

Address

Parent/Guardian Email

Parent/Guardian Phone

School Name

Grade Level

Youth T-Shirt Size

I consent to participate in the program(s) offered by IMPACT DELAWARE INC.

I give permission for my child to

participate in the program(s) offered by IMPACT DELAWARE INC.

I grant IMPACT DELAWARE INC permission to use my child's photograph and/or video images in promotional materials, including but not limited to website content, social media posts, and printed materials. I understand that these images may be used for public relations purposes and marketing efforts.

By signing below, I acknowledge that my child's participation in our program(s) may involve certain risks. I agree to release and hold harmless IMPACT DELAWARE INC, its directors, employees, and volunteers from any and all liability for injuries or damages that may occur during my child's participation in the program.

I authorize the release of my child's school grades, attendance records, and behavior information to IMPACT DELAWARE INC for the purpose of monitoring and supporting my child's progress in the program.

Today's Date

Youth Signature

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Parent/Guardian Signature

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PROGRAM APPLICATION

PROGRAM
APPLICATION