December 3-6, 2026 | Mikell Camp & Conference Center

Diocese of Atlanta

The Province IV Youth Leadership Gathering is the annual meeting of Episcopal youth and adult leaders from the twenty dioceses in the Southeastern United States that comprise Province IV. This year, we will gather at Camp Mikell (Toccoa, Georgia), the camp and conference of the Diocese of Atlanta.

For more on this gathering — including who's invited, travel information, facility details, and ways each diocese can contribute to this gathering — visit our website!

PARTICIPANT DETAILS

Participant Role

Participant Grade (2026-27)

Participant is...

LaypersonDeaconPriestOther

If other, please describe here:

Participant Profile Photo

First Name

Preferred Name

Last Name

Date of Birth

Gender

Pronouns

If 'other' was selected, please share your pronouns here:

Please indicate gender:

STUDENT HOUSING

Mikell's student dorms are organized into two areas: Crow Hill (formerly girls' hill) and Chapel Hill (formerly boys' hill). We invite our trans, nonbinary, and genderqueer participants to choose which dorm option would be most comfortable. If any participant has questions or concerns and would like to speak with a staff person, indicate that below and we'll call!

All Mikell dorms have been renovated to provide bathroom privacy for changing and showering, and Mikell policy requires all students to remain fully clothed inside the dorms.

All are welcome! Please select your housing preference.

CONTACT INFORMATION

Have you attended a Province IV Youth Leadership Gathering before?

YesNo

Participant Cell Phone

Participant Email

Street Address

City

State

Zip Code

Parent/Guardian Phone

Parent/Guardian Email

Please select your lodging preference

Roommate Name

If other was selected, please describe:

Diocese

T-shirt Size

VISITOR INFORMATION

Choose which best describes your role:

Please identify which nights you will be staying at Mikell:

Thursday, Dec 3Friday, Dec 4Saturday, Dec 5I will not need lodging for this event.

Please identify which meals you will be taking at camp:

DIETARY NEEDS + ACCESSIBILITY

Do you have any special dietary needs or preferences?

YesNo

Please select any of the dietary needs that apply to you:

VegetarianVeganDairy FreeGluten FreeOther

If you selected Other, please describe here:

Are there any additional health needs we can accommodate?

YesNo

We want to support your full participation. Please select all that apply:

Serious allergiesMobility (wheelchair access, walking assistance, etc.)Sensory (noise, lighting, etc.)Neurodivergence (ADHD, autism, etc.)Mental health support considerationsOther

Please describe how we can support your needs:

EMERGENCY CONTACT DETAILS

Additional Emergency Contact Name

Additional Emergency Contact Phone

MEDICATION + RELEASES

Are you bringing any medications to camp?

YesNo

Please list any current medications and their dosages

Health Insurance Company

Health Insurance Phone (for Authorization)

Policyholder Name

Policy Number

Group Number

MEDICAL RELEASE FOR MINOR PARTICIPANTS

As the parent or designated legal guardian of the Participant, I give permission for my child to attend & participate in the 2026 Province IV Youth Leadership Gathering, sponsored by Province of Sewanee (Province IV).

I affirm that, to the best of my knowledge, the Participant is able to safely take part in this Event. I understand that reasonable precautions will be taken to promote the health and safety of all Participants.

In consideration of The Province of Sewanee (Province IV) allowing the Participant to participate in youth ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Province IV, its employees, volunteers and agents from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities. Furthermore, we (I) [and on behalf of our (my) Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Province to furnish necessary transportation, food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Province for any liability sustained by said Province as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree (s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the afore mentioned youth pursuant to this authorization. Furthermore, we (I) give permission for an adult supervisor to administer any over-the-counter medication, as specified on the Participant’s medical form, my child may need during this event. Should it be necessary for our (my) youth to return home due to medical reason, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

Parent/Guardian Signature (type N/A if you are a staff person registering students)

MEDICAL RELEASE FOR ADULT PARTICIPANTS

As a participant at this Province IV gathering, I affirm that, to the best of my knowledge, I am able to safely take part in this Event. I understand that reasonable precautions will be taken to promote the health and safety of all Participants.

I acknowledge that participation in the Event involves inherent risks. I agree to release and hold harmless The Episcopal Church, Province IV, the Episcopal Diocese of Atlanta ("host diocese") and its staff, volunteers, and representatives from liability for injury or illness that may occur during participation in the Event, except in cases of gross negligence.

In the event of an emergency involving illness or injury, I authorize the host Diocese and its representatives to obtain necessary medical treatment for myself, including hospitalization, medication, anesthesia, or surgery, as deemed appropriate by licensed medical professionals.

I understand that the host Diocese does not provide medical insurance for Participants, and I agree that I am financially responsible for any medical care provided.

Participant Signature (type N/A if you are a staff person registering another adult)

ADULT PHOTO RELEASE

I hereby give permission for photographs and/or video recordings of me to be taken during this Event. I understand that these images and recordings may be used by The Episcopal Church, Province IV, and the Episcopal Diocese of Atlanta (collectively, “the Church”) for educational, ministry, and promotional purposes.

I understand that such use may include print publications, websites, social media, and other media formats now existing or developed in the future. I also understand that these materials will be used in a manner consistent with the mission and values of the Church.

Participant Signature (type N/A if you are a staff person registering a minor)

STUDENT PHOTO RELEASE

I hereby give permission for photographs and/or video recordings of my child to be taken during this Event. I understand that these images and recordings may be used by The Episcopal Church, Province IV, and the Episcopal Diocese of Atlanta (collectively, “the Church”) for educational, ministry, and promotional purposes.

If you are unable to grant this permission due to foster care status or other legal requirements, please contact the Missioner (contact information provided at the bottom of this form).

Parent/Guardian Signature (type N/A if you are a staff person registering a minor)

STUDENT TRANSPORTATION RELEASE
The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by and approved ADULT chaperones (21 years & older) while attending and participating in activities sponsored by Province IV. My youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation. We (I) the undersigned also, acknowledge that I have reviewed details regarding the event in which our (my) child is participating.

Parent/Guardian Signature (type N/A if you are a staff person registering a minor)

MIKELL COMMUNITY COVENANT

The following is the code of conduct we expect all participants* to abide by while participating in the Province IV Youth Leadership Gathering. 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.
All participants will uphold Safe Church policies in all interactions with students at all times. (Review our policies here.)
Bullying, fighting, abusive or offensive language, engaging in threats or 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.
There is zero tolerance for any form of sexual harassment, including physical and verbal actions. Inappropriate touching, sexual solicitations, or bodily exposure is strictly prohibited.
Weapons or items that appear to be/create the impression of dangerous weapons are prohibited, with the exception of items used as props for play and games, kitchen utensils, necessary equipment and tools, and other objects with a benign purpose that do not threaten Participants or create fear of harm (e.g. a bow and arrow for an archery event).
Student and Adult Leaders must treat student disclosures with respect and are prohibited from sharing students' private information with other students or adults, except as is needed to report disclosures or suspicions of abuse, self-harm, or harm to others. Leaders who suspect or receive disclosures of abuse, self-harm, or harm to others must report to Event Leadership immediately.
Tobacco products are not permitted.
Participants below the legal drinking age shall not use or have possession of alcoholic beverages. While supervising minors, adults are prohibited from drinking.
Illegal drugs and other non-prescribed controlled substances are prohibited.
Discrimination on any basis is prohibited by The Episcopal Church and will not be tolerated.
Responsible Officials shall apply these rules using common sense and good judgment, and not in an arbitrary or unreasonable manner.

*Participants are any adults, children, or youth participating in the event.

**Responsible Officials refers to adults who are acting for or in coordination with The Episcopal Church, Province IV, or the Diocese of Atlanta to host or lead the event.

PROVINCE IV MEETING EXPECTATIONS

Be on time and present at all meetings, organized activities, and meals. If you are going to be late, let your Diocesan Youth Leader or another adult know beforehand.
Do not enter the living space of others' without an invitation from those in that space. This includes bunks and bathroom stalls (dorms) and bedrooms/bathrooms (cottages).
We will begin each meal with a prayer. Meal attendance is not optional.
We will begin each morning session with prayer and meditation, as well as celebrate the Holy Eucharist at least once during the gathering. We will pray for each other daily and share prayer requests.
Remain within the bounds of the event space on Mikell property. Do not leave camp property for any reason, except in the event of an emergency in the company of at least two adults.
All youth participants must be in their own sleeping area between the hours of 11pm and 7am. Quiet hours are between 11p-7a.

DURING MEETING TIMES

Strive to uphold the promises made in our Baptismal Covenant.
One person speaks at a time using "I" statements.
If you want to share sensitive or confidential information, inform the group before sharing.
Be direct and specific in your statements
Speak for yourself and not for the group or others.
Be honest and open with ideas and feelings.
Be responsible for your own needs, actions, and thoughts.

I have carefully read and comprehended the expectations listed above. I acknowledge and agree to abide by the behavioral expectations created for the 2026 Province IV Youth Networking Meeting. In the event that I violate any of these expectations, I consent to being sent back home at my own expense.

Signature of Participant

TRANSPORTATION + TRAVEL

Which of the following best describes your travel plans to Mikell Camp & Conference Center?

Our group is flying into a local airport and renting a car to drive to Mikell.Our group is flying into a local airport and sharing a car with another group to drive to Mikell.Our group is driving from our Diocese and stopping to pick up another group on the way.Our group is driving from our Diocese directly to Mikell.Other

If other was selected, please describe:

Which airport will your group's flight be leaving from?

Which airport will your group be flying into?

Which Diocese will you be traveling with?

After the event, which best describes your plans to travel home?

We have an early flight and will leave before wake-up (7:15a) on Sunday.We have a long drive and will leave before breakfast (8a) on Sunday.We will leave after breakfast (8a) on Sunday.Other

If other was selected, please describe:

PAYMENT

How will you be paying?

I will be paying by checkI will be paying by credit card

Registration Fees:
Adult (Single Room): $465
Adult (Shared Room): $370
Student Participant: $370

Checks should be mailed by October 30, 2026 to:

The Episcopal Diocese of Atlanta
c/o Holle Tubbs
2744 Peachtree Road NW
Atlanta, Georgia 30305

Memo: Province IV Gathering

Please confirm the amount you will be paying by check:

Registration Fees:
Adult (Single Room): $465
Adult (Shared Room): $370
Student Participant: $370

Checks should be mailed by October 30, 2026 to:

The Episcopal Diocese of Atlanta
c/o Holle Tubbs
2744 Peachtree Road NW
Atlanta, Georgia 30305

Memo: Province IV Gathering

Please confirm the amount you will be paying by check:

Confirm your registration numbers below:

# of Adult Registrations (Single Room/$465)

# of Adult Registrations (Shared Room/$370)

# of Student Registrations (Dorm/$370)

Name on Card

Card Number

Code

Billing Email