Registrations

First Names*

Last Name*

Age*

Street Address*

Suburb/Town

City*

Contact Number*

Email*

Church ie. City Impact North Shore, Balclutha etc*

Please state if you have any medical conditions

Emergency Contact Name

Emergency Contact Number

Have you been on a Summer Impact?
Yes
No

Venue/s

Year/s

Why do you want to go on Summer Impact*

North and South Island Payment Packages. Please carefuly select your appropriate fee options*
Week One only - (27th Dec - 3rd Jan) - $199
Week Two only - (11th Jan - 13th Jan) - $99
Week One and Two - $249
South Island Only - (27th Dec - 2nd Jan)
South Island - Alexandra - (27th Dec - 3rd Jan)

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