SURGE Registration Form

SURGE is DCN's high-energy student outreach program for 6th-12th graders that meets on Thursday nights from 6:30-8:30 during the school year. It features an exciting combination of great music; fun games, stunts and activities; multimedia; engaging age-appropriate discussion groups; and a relevant talk each week designed for students to get to [KNOW God].

Please register for the 2011-12 season by completing the registration form below. NOTE: Each registration form must be completed by that student's parent or legal guardian.

STUDENT INFORMATION

First Name: *

Last Name: *

Gender: * select...MaleFemale

Address: *

City: *

Zip Code: *

Home Phone: *

Mobile Phone:

E-mail:

Grade (Fall 2011): * select...6th7th8th9th10th11th12th

Birthday:

PARENT/LEGAL GUARDIAN INFORMATION

Parent 1 First Name: *

Parent 1 Last Name: *

Parent 1 E-mail: *

Parent 1 Phone: *

Parent 1 Phone (emergency/urgent): *

Parent 2 First Name:

Parent 2 Last Name:

Parent 2 E-mail:

Parent 2 Phone:

Parent 2 Phone (emergency/urgent):

LIABILITY & CONSENT

Known allergies, medical restrictions or special instructions? If yes, please describe: *

Consent & Liability Release: * Type Agree

After reading the Consent & Liability Release type the word Agree above if you agree with and will abide by it.

ADDITIONAL INFORMATION

How often does your family attend church?: * select...NeverMajor holidays5-11 times a year1-2 times a monthMost every week

How did you learn about SURGE?: *