SURGE WINTER 2020 @ FBC MOUNT VERNON

February 21–22Â
6th — 12th Grade
Participants will return to their homes to sleep
Cost: $30, includes T‑Shirt, Materials, Snacks & 3 Meals
Applications due by February 14, 2018
2/22 6pm-10pm, Super & Snack Served
2/23 9am-4pm, Breakfast, Lunch, & Snack ServedÂ
You can download, print, and send in your registration form and payment byÂ Clicking Here
Or by filling out the form & payment below ($1.20 PayPal fee included)
Please mail to Daniell Baptist Association, P.O. Box 388, Ailey, GA 30410

Username^*

Password^*

Password must be at least 7 characters long.

Enter password again^*

Password must be at least 7 characters long.

First Name^*

Last Name

Age^*

Gender^*

T‑Shirt Size (Adult Sizes Only)^*

Current School Grade

Email^*

Address

Address Line 1 ^*

City ^*

State or Region ^*

Zip ^*

Parent/Guardian Name^*

Parent Cell Phone

Parent Home Phone

Parent Work Phone

Parent Email^*

Emergency Contact Name^*

Emergency Contact Phone Number^*

Please list any allergies/medications or other medical conditions:

Name of Insurance Company Covering Camper^*

Policy Number:

Name of Policy Holder:

Church You Attend^*

Member of Church?^*

By Checking & Tying your name below you agree: As a participant I agree to abide by all the rules set forth by the DBA SURGE committee. I further understand that failure on my part to comply with rules and directions given by the event organizers and youth leaders that are serving as counselors and chaperones of the event will merit my immediate dismissal at my parent/guardianâ€™s expense.

Camper Check^*

I Agree

Camper Signature^*

Date^*

By Checking and Typing your name below you agree: As a parent/guardian I agree to allow my child to attend Winter Surge. I understand that the event organizers, the DBA, individual DBA churches or FBC Mt. Vernon, will not be held liable for injuries incurred as a result of my childâ€™s attendance at this event. Should injury or illness, other than minor, arise, I give my permission for medical care to be provided. I shall be fully responsible for payment of such cost. I also give my permission for any photographs taken of my child to be used for possible promotion purposes. I also give my permission for my child to be transported from FBC Mt. Vernon to participate in a local mission project.

Parent/Guardian Check^*

I Agree

Parent/Guardian Signature^*

Date^*

Surge Winter^*

Schedule: Friday, February 21 arrive for supper & activities @ 6:00 pm Depart for home @ 10:00 pm Saturday, February 22 arrive for breakfast and a full day of activities @ 9:00 am. Depart for home @ 4:30 p.m.

If you have any questions, please call Laura Hay at 253‑0041 or Tabitha Braddy at 253‑2896

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