Surge Encounter 2019 Student Registration
Name of Event: Surge Encounter 2019
Dates of Event: Wednesday-Saturday, June 19-22, 2019
Location: Colorado Christian University
8787 W Alameda Ave, Lakewood, CO 80226
Website: www.ccu.edu (please refer to website for more information)

Eligibility requirement: Youth must have completed 6th grade to attend Surge Encounter 2018. Permission Slip is required for this event. All forms & payments must be completely filled out and submitted in order to be officially registered for this event. Forms must be completed by PARENTS or LEGAL GUARDIANS.

Cost: $240 (Includes lodging, meals, activities, and t-shirt)
$75 deposit due by Sunday, March 24th. Additional $75 payment due by Sunday, April 21st. Final balance due by Sunday, May 19th. Leadership reserves the right to prohibit youth from attending the event if all monies are not collected by the due dates. Youth may bring additional money for concessions and gift store.

One registration form per youth attending.

Email address *
Student Name *
Your answer
Address, City, Zip *
Your answer
Gender *
Grade (2017-2018 School Year) *
T-shirt Size (Adult sizes) *
Home Church
Your answer
Roommate Preference
All youth must agree to room with each other. We do our best to meet all roommate requests.
Preferred Roommate #1
Your answer
Preferred Roommate #2
Your answer
Preferred Roommate #3
Your answer
Preferred Roommate #4
Your answer
Preferred Roommate #5
Your answer
Medical Information
Will your student need to receive medication during the event? (If yes, please fill out the Medication Permission Form) *
Note any physical/medical limitations or conditions, activities (basketball, volleyball, running, etc.) prohibited:
Your answer
Note any food allergies or restrictions:
Your answer
Emergency Contact
Please list an emergency contact name and phone number other than Parent/Legal Guardian.
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
AUTHORIZATION, WAIVER, AND RELEASE
I hereby consent for my child(ren) to participate in 2018 Burn Student Ministry Surge Encounter Summer Camp sponsored by Burn, the Student Ministry of New Creation Church and waive and release the Church from any and all claims, cost, liabilities, expenses, decrees or judgments, including attorney’s fees and court costs arising out of my child’s participation in that activity sponsored by the Church, or any accident, illness, or injury resulting therefrom, or in travel to or from such participation and hereby agree to indemnify and hold harmless the Church from and against any and all such claims.

I also acknowledge that should at any point and time my child’s behavior be deemed and observed to be inappropriate, dangerous, disrespectful or place any other person(s) in danger, that I will immediately take action to come and pick my child up from the event within a reasonable amount of time.

As used in this authorization, waiver, and release form, the term “Church” shall be understood to include, not by way of limitation, all paid and unpaid staff, committee, board, and membership.

I further give my consent for any adult leader of that activity sponsored by the Church to secure emergency medical and surgical treatment for my child which may be considered to be necessary in the situation in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved.

This authorization, waiver, and release form shall be valid not only for the specific activity being attended, but for any activity sponsored by the Church in 2018 in which my child participates, unless revoked in writing prior to the date of the activity.

Parent or Legal Guardian Name *
Your answer
Parent/Legal Guardian Preferred Phone # *
Your answer
Date *
MM
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DD
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YYYY
Payment Information
Cash or check only. Please make checks payable to New Creation Church. Drop off or mail checks to New Creation Church, 737 Bross St., Longmont, CO 80501

Cost: $240 (Includes lodging, meals, activities, and t-shirt)
$75 deposit due by Sunday, March 24th. Additional $75 payment due by Sunday, April 21st. Final balance due by Sunday, May 19th.

A copy of your responses will be emailed to the address you provided.
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