Student Information

First Name

Last Name

Preferred Name (if different than first name)

Date of Birth

Grade

T-shirt Size

Pronouns (e.g. he/him, she/her, they/them)

Gender

Parent/Guardian Email

Address Line 1

Address Line 2

City

State

Zip Code

Your home parish/church

Medication Information

Insurance Name

Insurance Group Number

Insurance Policy Number

Insurance Phone Number

Special dietary needs or allergies:

Please list any prescription medications you'll be bringing to camp, along with dosage information. Example: "Wellbutrin 150mg / Take once a day after a dinner"

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact Phone Number #2

Typing your name in the signature fields below acts as your official signature and certifies that you have personally reviewed the information presented and will comply with our guidelines.

Below is the code of conduct we expect all youth to abide in while participating in all Diocesan Youth Events.

EYCDIOATL Community Covenant

It is the policy of The Episcopal Diocese of Atlanta (“Diocese”) that all events and activities conducted by the Diocese or on its property observe the following guidelines, which are to be interpreted in a manner consistent with the mission and doctrine of The Episcopal Church.

Responsible officials will model and promote behavior of and towards all Participants in keeping with the Baptismal Covenant found in the Book of Common Prayer.
Responsible officials will uphold all Safe Church policies (including Safeguarding God's Children and Safeguarding God's People) in all interactions with students at all times.
Bullying, fighting, abusive or offensive language, engaging in threats/coercion, or any other aggressive behavior is prohibited.
Any activity that presents a serious risk of personal injury or emotional harm to any Participant or other person is prohibited.
Sexual advances towards or unwanted, inappropriate, or offensive touching of Participants is prohibited.
Weapons or items that appear to be or create the impression of dangerous weapons are prohibited. Props for plays and games, kitchen utensils, utilitarian equipment and tools, and other items with a benign purpose that do not threaten Participants or create realistic and actual fear of harm are permitted if otherwise appropriate. (For example: a bow and arrow at an archery event or a cutting tool on a camping trip may be appropriate under all of the circumstances.)
When possible, all students shall be housed according to gender identity.

Camp Mikell does not currently have dedicated nonbinary dorms. Nonbinary students are invited to select housing on either Crow Hill or Chapel Hill.

All Adults and Students in leadership positions shall treat student disclosures with respect and are prohibited from sharing students’ private information with other students.
All Adults and Students in leadership positions shall report the following to the Missioner or Volunteer Staff immediately:

Disclosures of physical, sexual, emotional, or verbal abuse;
Disclosures of self-harm or thoughts of self-harm;
Disclosures of plans to harm others.

Tobacco products are not permitted and shall not be used.
Participants below the legal drinking age shall not use or have possession of alcoholic beverages. During Diocesan retreats and events, chaperones are prohibited from drinking. This has no application to proper participation in communion.
Illegal drugs and other controlled substances for which the person in possession has no prescription are prohibited.
Age-appropriate play or normal physical activities are permitted if they do not entail or threaten injury, offensive physical contact, or other offensive or improper conduct.
Discrimination on any basis prohibited by the Episcopal Church is not to be tolerated, consistent with other Diocesan policies.
Adults shall apply these rules using common sense and good judgment, and not in an arbitrary or unreasonable manner.

For purposes of this policy, the following terms have the stated meaning:

“Participants” means children or youth participating in Diocesan events.

“Responsible Officials” means persons who are acting for or in cooperation with the Diocese or have any responsibilities or authority in connection with an event.

I have read and commit to fulfilling the Episcopal Youth Community Covenant.

Signature of Student

Signature of Parent or Guardian

Permission, Medical, and Liability

As parent or guardian of Participant, I attest that they are in good health and have no physical, mental, or emotional reason that would prohibit them from participating in Event. I understand that every precaution has been taken to assure the good health and safety of all Participants.

I therefore waive any liability of the Episcopal Diocese of Atlanta ("The Diocese") or its representatives for any injury or death that occurs while attending the Event.

I grant The Diocese permission to hospitalize, secure treatment for, and/or order injection, anesthesia, or surgery for my child, and to have my child medically treated by a licensed physician, nurse, or hospital staff during the time period of the Event.

I also understand that The Diocese does not provide medical insurance for the cost of any required treatments and that all expenses would be the responsibility of the family of the Participant requiring treatment.

Parent/Guardian, by typing your name below, you are attesting that you consent to the above paragraph (Permission, Medical, and Liability)

Signature of Parent or Guardian

Photo Release

I hereby give my consent to all photos and/or video taken of my child by The Diocese. I understand that any such photos or videos are the property of The Diocese and may be used by a parish or The Diocese for instructional or promotional purposes determined by The Diocese in broadcast and media formats now existing or created in the future.

**If you cannot consent to this due to foster care or other legal requirements, please contact the Missioner (contact information at bottom of form).**

Parent/Guardian, by typing your name below, you are attesting that you consent to the above paragraph (Photo Release)

Signature of Parent or Guardian

Housing

In conformity with the policies and doctrine of The Episcopal Church, the Office of Youth Ministries does its best to house participants in accordance with their expressed gender identity. Safe and private bathroom, shower, and changing spaces will be provided and Participants will remain fully clothed at all times while in common areas .

By signing below this registration, you acknowledge the existence of this policy and consent to its application at the event noted in the description of this form ("Event") for the duration of the period in which Participant is at Event.

If you wish to discuss the application of this policy, please contact the Diocesan Youth Missioner (contact details are at the bottom of this form).

Payment Information

The retreat fee is $150/student.

Name on Card

Card Number

Code

Billing Email

Retreat Packing List

Hand sanitizer
Clothes you can layer for warmth
Close-toed shoes
Instrument (if you play)
Water bottle
Sheets for a twin bed OR sleeping bag/blanket
Pillow
Toiletries
Towel
Pajamas (top and bottom)
Prescription medication as needed
Cabin snack (optional)

Students can bring their phone, but all electronics will be left in the cabin during program time.