We’re Making An Impact

2025 CI Scholars Program

Mondays and Tuesdays
September 8 – November 18, 2025 | 3:00 PM – 5:00 PM
City Impact 1035 North 33rd Street Lincoln, NE 68503

Call 402-477-8080 for more information.

City Impact is thrilled to announce the launch of its free CI Scholars Program this fall! This program aims to help K-8th grade students build confidence, enhance their academic skills, and reach their full potential.

CI Scholars Program Application Form 2025

CI Scholars Program Application

Parent Information

First Name:

Last Name:

Email:

Phone:

Address

Parent Address Line 1

Parent Address Line 2

Parent City

Parent State

Parent Zip Code

Parent Country

Parents Relationship to Child:

I give permission for my child’s image, captured in photos/videos or other media formats, to be used by City Impact in publications, on its website, and in social media posts at its sole discretion.

Yes

Child’s Information

Click the round '+' symbol (right-side) to add up to six (6) Children:

Child's First Name:

Child's Last Name:

Child’s Date of Birth:

Name of School Child Attends:

Student’s Grade In School (Fall 2025):

Student's Academic Focus Subject:

Any known learning challenges or IEP/504 plan?

Does the child have any allergies (including food allergies) or other medical condition(s)?

Doctors Information

Doctors Name:

Doctors Phone:

Name Of Preferred Hospital (In case of emergency.)

Emergency Contacts

Click the round '+' symbol (right-side) to add an additional Emergency Contacts:

Emergency Contacts First Name:

Emergency Contacts Last Name:

Emergency Contacts Email:

Emergency Contacts Phone:

Emergency Contacts Address:

Emergency Contacts Address 2:

Emergency Contacts City:

Emergency Contacts State:

Emergency Contacts ZIP/Postal Code:

Authorized Child Pick-Up Contacts

I give permission for my child to be picked-up, dropped-off, transported, and released to Authorized Child PickUp Contact(s).

Yes

Click the round '+' symbol (right-side) to add an additional Child Pick-Up Contact:

Pick-Up Contacts First Name:

Pick-Up Contacts Last Name:

Pick-Up Contacts Email:

Pick-Up Contacts Phone:

Relationship to Child:

Waiver Agreement Consent

Please read this agreement carefully before indicating your consent below.

In consideration of my child or legal ward’s voluntary participation in the Program and related activities organized or sponsored by City Impact, a nonprofit charitable organization, I, the undersigned parent or legal guardian, hereby agree to the following terms on behalf of myself, my child or ward, and our respective heirs, assigns, executors, and administrators:

1. Release of Liability

I hereby release, discharge, and hold harmless City Impact, its officers, directors, employees, agents, volunteers, representatives, and affiliated parties (collectively, “Released Parties”) from any and all claims, demands, causes of action, or liability arising from or related to any injury, illness, loss, or damage to person or property that may occur to my child or ward as a result of participation in the Program or any associated activities, whether arising from the negligence of the Released Parties or otherwise.

2. Assumption of Risk

I acknowledge and agree that participation in the Program involves inherent risks, including the risk of physical injury. I certify that my child or ward is voluntarily participating and is physically fit and able to engage in such activities. I assume full responsibility for any and all risks of injury or damages that may result.

3. Emergency Medical Authorization

In the event of a medical emergency, I authorize City Impact staff, representatives, or volunteers to seek medical treatment for my child or ward, including transportation to a medical facility. I agree to be responsible for all costs associated with such treatment. I also authorize City Impact to administer any medication I provide for my child or ward, in accordance with my written instructions.

4. Media Release

I grant permission to City Impact to photograph, video record, and/or quote my child or ward during the Program. I authorize the use of such media for promotional, marketing, fundraising, and educational purposes in print, online, or other formats, without compensation or need for further approval.

5. General Consent to Participate

I hereby give my full permission for my child or ward to attend and participate in all activities associated with the City Impact Program. By signing or submitting this form, I confirm that I have read and fully understand the terms of this Liability Waiver and Consent Agreement, and that I voluntarily agree to be legally bound by it.

By checking this box I am providing my digital signature indicating my acceptance of terms within this agreement, waivers and consent set forth herein, and any indicated related agreements.

Parents Digital Signature

Parents Full Name (Signature):