CLASS REGISTRATION Sign up for our 8-week Spring Trimester that starts April 25, 2024 IMPACT Registration Form Name(Required) First Last Home Phone(Required)Email(Required) Mobile Phone(Required)Mobile Phone Carrier(Required) I agree to receive occasional text messages from Love INC.(Required) Yes No Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Church where you regularly attend (optional) How did you hear about IMPACT? (optional) Why are you considering the IMPACT program? What led you to sign up?(Required) I am registering for the following course:(Required)NOTE: Our campus is located at South Fellowship Church on Thursday evenings. Our no-cost dinner starts at 5:45pm and all classes run from 6:30-8pm. Sign me up for How We Love Sign me up for Lifestyles Sign me up for Forgiveness Sign me up for Safe People This is your invitation to participate in IMPACT. Through a caring and trusting class relationship, the mission of IMPACT is to walk alongside you and provide guidance as you work toward specific life goals. Our Facilitators and Discussion Group Leaders are caring and trained volunteers who have agreed to guide people toward greater self-sufficiency using a specific classroom curriculum. To achieve success and make the best use of your and our volunteers' time, certain requirements are important. Please review these statements and check the boxes beside each one.(Required)I commit to the following: To participate in my IMPACT class weekly and to be on time for each class. To send an email to my Class Facilitator if I am unable to attend class on any given week. To complete each week's assignments, which will help me better achieve my life goals. To honor others in the IMPACT community and host Church through my respectful and positive behavior. I AGREE to ALL of the above statements. (this must be checked to complete your registration) Childcare Registration If you have kids ages 6 months to 12 years of age, we are happy to have them be a part of IMPACT Kids. Please complete the information below for each child you will be bringing to IMPACT. Our Registrar will follow up with you to gather more information about your children to ensure that we are 100% ready to host them at IMPACT Childcare!Child 1 Name of Child 1 Age Known Allergies Will they participate in meal time? Yes No Potty Trained? Yes No Child 2 Name of Child 2 Age Known Allergies Will they participate in meal time? Yes No Potty Trained? Yes No Child 3 Name of Child 3 Age Known Allergies Will they participate in meal time? Yes No Potty Trained? Yes No Child 4 Name of Child 4 Age Known Allergies Will they participate in meal time? Yes No Potty Trained? Yes No Photo/Video/Story Release Permission(Required)I hereby grant Love INC permission to publish photographs/videos and/or my story for editorial, advertising, and promotional purposes for use in any "Love Stories" print or electronic media. I agree that Love INC will own the copyright to these materials and Love INC will only use my first name. Check this box to permit the use of family info and photos. Yes No Confidentiality Agreement(Required)I will protect the confidentiality of all individuals- whether participant, volunteer, or staff. I agree that I will not disclose or discuss personal information that is shared in confidence, with anyone other than the appropriate Love INC/IMPACT leadership. I will not be involved in gossip or negative conversation that could reflect badly on those who are serving or being served, or on the ministry of Love INC/IMPACT; with the exception of if someone threatens to harm themselves or someone else (calling 911 may be the most appropriate response.) Yes No We collect and use your personal information in accordance with our privacy policy. By providing your contact information you agree that we may text, call, or email you.(Required) I agree to the privacy policy.PhoneThis field is for validation purposes and should be left unchanged.
