Ultimate Impact

Parent Name *

First Name

Last Name

Phone *

(###)

###

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Child's Name *

First Name

Last Name

My child is part of the following after-school program: *

Bret Harte

Buena Vista

El Dorado

ER Taylor

Paul Revere

Vis Valley Elementary

OnePurpose

Other

I will pick my child up at: *

You have the option to pick our child up at two locations, depending on what's easiest for you.

Their after-school program at 6pm

Bret Harte Elementary School at 6pm