The Overnight begins Nov 7 at 7:00pm and ends Nov 8 around 1:30pm.

PARTICIPANT DETAILS

First Name

Preferred Name

Last Name

Age

Grade

T-shirt Size

Gender

Pronouns

Parish

Parent Email

Student Email

Address Line 1

Address Line 2

City

State

Zip Code

Additional Information

Please share any information that may help us provide a safe, respectful, and supportive experience for your student. This may include:

Allergies or special dietary needs
Medication information
Custody arrangements or transportation restrictions
Behavioral, sensory, or mental health considerations
Past experiences that may affect participation or emotional safety
Any other information you'd like us to know

EMERGENCY CONTACT & INSURANCE

I authorize representatives of the Episcopal Diocese of Atlanta to administer non-prescription medications (e.g., Tylenol, Benadryl) in accordance with label instructions if deemed necessary.

YesNoCall before administering OTC medication

Medical Insurance

Name of Insurance Policyholder

Insurance Provider

Insurance Phone

Insurance Policy Number

Insurance Group Number

Emergency Contact Information

Emergencies can happen outside office hours — please make sure that all phone numbers provided allow us to reach you on nights and weekends if needed.

Primary Emergency Contact Name

Relationship to Participant(s)

Phone

Can this number receive texts?

Secondary Emergency Contact Name

Relationship to Participant(s)

Phone

Can this number receive texts?

EXPECTATIONS, WAIVER OF LIABILITY & MEDICAL CONSENT

Community Covenant & Expectations

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 for the safety of adults

who are acting in cooperation with the Diocese to exert authority or supervision at an event ("Responsible Officials") and minor participants ("Participants), 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 with all participants that is consistent with our Baptismal Covenant.
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.
The following is strictly prohibited at events sponsored or hosted by the Diocese:

Bullying.
Physical violence.
Discrimination based on race, ability, socioeconomic status, age, orientation, gender identity, or gender expression.
Sexual advances (including unwanted, inappropriate, or offensive touching or language) toward event participants.
Abusive or offensive language.
Engaging in threats or coercion.
Engaging in other aggressive behavior.
Tobacco products and paraphernalia.
Non-eucharist alcohol.
Illegal substances, including the improper use of prescription medications.
Any activity that presents a serious risk of physical injury or emotional harm is prohibited.
Weapons or items that appear to be or create the impression of dangerous weapons. Program and game props, 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 may be permitted if otherwise appropriate, e.g. a bow and arrow at an archery event or a cutting tool on a camping trip.

When possible, all students shall be housed according to gender identity.

Although Camp Mikell does not currently have dedicated nonbinary dorms, nonbinary participants are invited to select housing on either Crow Hill or Chapel Hill. Based on staffing numbers, we will do our best to accommodate particular housing needs as they arise.

All Responsible Officials and Participants in leadership positions shall treat student's private information — including, but not limited to, disclosures of suicidality or self-harm; allegations of abuse or neglect, reports of Safe Church violations — with discretion and respect.
Responsible Officials and Participants are prohibited from sharing students’ private information with other students, with the exception of Responsible Officials disclosing information in the interest of safety.
All Responsible Adults and Participants in leadership positions must report the following to the Missioner or Leadership 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.

Age-appropriate play and physical activities are permitted if they do not entail or threaten injury, offensive physical contact, or other offensive or improper conduct.
Responsible Officials shall apply these rules using common sense and good judgment, and not in an arbitrary or unreasonable manner.
Participants who violate Covenant guidelines may be sent home or otherwise suspended from event activities.

The Diocese or its designated Responsible Officials will make every effort to notify parents/guardians of disciplinary measures that require the student's suspension of participation in the program.

Media Release

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

Housing Policy

In conformity with the policies, canons, 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 changes spaces will be provided whenever possible and Participants will remain fully clothed at all times while in common areas.

Acknowledgment of Risk & Liability Waiver

By signing below, I acknowledge that youth event activities carry inherent risks, including but not limited to physical injury, exposure to weather, allergic reactions, and transportation accidents. I voluntarily assume all such risks on behalf of myself and/or my child(ren).

In consideration of mine or my child(ren)’s participation, I agree to release and hold harmless the Episcopal Diocese of Atlanta, Camp Mikell, participating parishes, event staff, clergy, volunteers, and agents from any and all claims of liability arising from injury, illness, or loss sustained during or resulting from participation in diocesan youth events, except in the case of gross negligence or intentional misconduct.

General Medical Consent

I, the undersigned parent/legal guardian, do hereby authorize adult staff and designated leadership volunteers of the Episcopal Diocese of Atlanta to consent to any necessary medical treatment for my child(ren) in the event of illness or injury while participating in diocesan youth ministry events. I understand that all reasonable attempts will be made to contact me first.

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.

By typing my full name below, I affirm that this serves as my legal signature and that I consent to all terms and permissions outlined in this form. I understand that this electronic signature is the equivalent of a handwritten signature for all purposes related to diocesan youth ministry events.

Parent/Guardian Full Name (Typed Signature)

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PAYMENT

Registration fees cover Friday dinner, Saturday breakfast, snacks/drinks, and an event t-shirt.

How many people are you registering for this event?

Name on Card

Card Number

Code

Billing Email

Do you need a receipt?

We don't want cost to be a barrier to any student's participation.

Please email htubbs@episcopalatlanta.org if you need scholarship assistance for this event.