SURGE WINTER - Daniell Baptist Association

You can register below or click here to download your Winter Surge Application

Registration Due By February 17

Campers First Name^*

Campers 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 child’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^*

Schedule: Friday, February 26 arrive for supper & activities @ 5:30 pm Depart for home @ 10:00 pm Saturday, February 27 arrive for breakfast and a full day of activities @ 9:30 am. Depart for home @ 4:00 p.m.

If you have any questions, please call Laura Hay at 253‑0041

Surge Winter (Includes PayPal Fee)^*

Select a payment method^*

Pay Offline

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