IMPACT Application and Medical Release Form
Mail to:IMPACT Happening Ecumenical, Inc. 7806 Chadwick Prairie Village, KS. 66208
"IMPACT" is a spiritual weekend experience for persons age 17 (and graduated from high school)
to age 25. It does not provide a climate for solving personal problems in need of counseling, but
is designed to help young adults find and/or deepen their personal relationship with God through
Jesus Christ. It also seeks to encourage participation in a community of faith and a local church.
NAME:________________________________________AGE:___________MARRIED: Y or N
Home Address:_____________________________________________________________
City:_______________________________________State:_________Zip:___________
Phone:__________________________e-mail:___________________________________
Parents/Guardians Names:__________________________________________________
Address:__________________________________________________________________
City:_______________________________________State:_________Zip:___________
Phone:____________________________________________________________________
College:__________________________________________________________________
Year: F_____So_____J_____S_____
Address at school:________________________________________________________
City:_______________________________________State:_________Zip:___________
Phone:____________________Email:__________________________________________
Member of Church?__________Name of Church:________________________________
Location:_________________________________________________________________
List any special health or dietary needs:______________________________________________________________
____________________________________________________________________________________________
Why do you wish to attend "IMPACT"?:____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
The fee for the weekend is $50 per person. Please attach check payable to Happening Ecumenical, Inc.
Send to 7806 Chadwick, Prairie Village, KS 66208
Any questions may be directed to Sheri Thompson, Executive Director at 913-341-5121 or email at Happec@aol.com