River WPB: Youth Fire Week 2026 Application Form

Student's Information

First Name *

Last Name *

Gender *

Male

Female

Birthdate *

Phone Number

Email Address

Primary Care Physician's Full Name *

Primary Care Physician's Phone Number *

Does this student have any allergies? *

Yes

No

Did this student have any medical conditions in the past 3 months? *

Yes

No

List every medication this student has taken in the past 3 months and is currently taking. *

Does this student have any medications that they will be required to take while at Youth Fire Week? *

Yes

No

Can this student swim? *

Yes

No

Questions for the student

How often do you attend Surge Youth? *

How has Surge Youth/River Church impacted your life and what are some things that God has done in your life since attending Surge Youth/River Church? *

Why do you want to attend Youth Fire Week? *

What are some things you're believing that God will do in your life at Youth Fire Week? *

Parent/Guardian's Information (Emergency Contact No. 1)

First Name *

Last Name *

Gender *

Male

Female

Birthdate *

Phone Number *

Email Address *

Address *

What is your relationship with this student? *

Parent/Guardian Information (Emergency Contact No. 2)

First Name *

Last Name *

Gender *

Male

Female

Birthdate *

Phone Number *

Email *

What is this person's relationship to the student? *

I understand that this is merely an application form and does not mean this student has automatically been approved by Pastors and leadership to join Surge Youth at Youth Fire Week 2026. *

I understand that if/when this student is approved to join Surge Youth at Youth Fire Week 2026, I will be able to officially register this student and make a payment for this student to attend Youth Fire Week 2026 with Surge Youth. *

I agree that when this student travels with Surge Youth & River Church WPB, I will abide by the rules and policies set forth by the Surge Youth & River Church WPB leaders traveling with this student. *

By filling out this application, you are agreeing to abide by the rules set forth by the Pastors of River Church WPB and Surge Youth leadership. You are agreeing that you and this student will adhere to all of the rules and requirements of traveling with Surge Youth. You understand that these rules were created to ensure this student's safety, so that he/she can get the best experience at Youth Fire Week.

By signing your name below, you are acknowledging that you are at least 18 years of age or older and are agreeing to the terms above. *

Type your full name below

Do you have any further comments or questions concerning Youth Fire Week? *

Yes

No