Social Club Registration – Welcome to Impact's TLC

Participant Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Mobile Phone *

Date of Birth *

T-shirt Size (unisex) *

Parent/Caregiver Name *

First

Last

Parent/Caregiver Phone *

Parent/Caregiver Email *

Emergency Contact Name

First

Last

Emergency Contact Phone

Emergency Contact Email

Diagnosis *

Concerning behaviors, i.e., aggression, self-injury, previous 1:1 required? *

Payment Information

Welcome to Impact’s TLC Social Club Registration. $20 nonrefundable registration fee is due within 48 hours of registering. Payment can be dropped off at any Impact location.
Credit card payments can be taken over the phone by contacting mary@impactacademyschool.org or beth@impactacademyschool.org. A service fee will apply for all credit card payments.
$300 session fee is due on March 6, 2024