*Name

*Address

*City *State *Zip

*Home Phone Work Phone

*Birthdate (mm/dd/yy) *Age

Email:

Mobility:
*I use a (choose one)

Wheelchair Walker Scooter Ambulatory

Send me a scholarship application

I am interested in a monthly pre-payment plan

*Attendant Status:
(choose one)

I am coming independently

I am bringing my own attendant,
his/her name is

I will need Overcomers to provide a volunteer/attendant for me

Session
*I WANT TO ATTEND:
(choose one)

Overcomers Session I - July 20 - 24
Pastor: - Jim Loveland
$50.00 deposit required with application
Registration deadline: June 12

Overcomers Session II - August 16 - 21
Pastor: - Loren Winn
$50.00 deposit required with application
Registration deadline: July 9

Autumn Getaway - October 26 - 30
Pastor: - Bishop Charles Singletary
$50.00 deposit required with application
Registration deadline: September 18

Christian Overcomers Staff:
Debbie Neilley
Sharon LaForge

Cancellation policy: Refund given the non-refundable deposit if cancellation is received 2 weeks before camp starts.

Confirmation and additional information will be sent upon receipt of this form and your deposit.

Filling out this application does not guarantee acceptance into our program.