Camper's Name*

First NameLast Name

I confirm that I am the parent/legal guardian filling out this Mississippi Youth Camp Application for my child.*

Yes

Camp Cost

$185.00 Before April 3, 2023 Includes Camp Shirt

$200.00 Before May 1, 2023 Includes Camp Shirt

$250.00 After May 1, 2023 Walk-On Price *Camp shirt included while supplies last

All balances are due by May 1, 2023 or a late fee will be applied.

*$25 deposit is required to complete application. Must be recieved within 10 business days.

Check/Money Order Payments:

Make checks payable to:

Mississippi Church of God State Fund

Mail Checks or money orders to:

ATTN: Youth Camp

1000 Lake Village Circle

Brandon, MS 3904

Cash Payments:

We do not recommend mailing in cash. You will need to bring that directly to our offices.

Church Payments:

If your church is fundraising and/or paying for your student(s) please have your Pastor contact Jennifer Smith at ydsec@mscog.org or call the MSCOG State Office at 6013722714.

Camps Choices

Primary School Camp (Ages 7-11) June 12-16

This camp is recommended for kids in elementary school who attend kids church at their local church.

High School Camp (Ages 15-18) June 19-23

This camp is recommended for students in high school who attend youth group at their local church.

Middle School Camp (Ages 12-14) June 26-30

This camp is recommended for students in Jr. high or Middle School who DO NOT attend kids church at their local church.

If you have questions about which camp is best for your child please call the State Office at 601-372-2714.

Have you previously attended MSCOG youth camp?

YesNo

Camp Choice*

Choose which camp your child will attend.

My child is a 2022 Super Camper Winner

Yes

Church Name*

Pastor's Name*

Camper's Shirt Size*

Roommate Preference (list their name & church)

Cabin Leader Preference (list their name & church)

Camper Information

Please answer every question to the best of your knowledge. If no answer is available repond with NA.

Camper's First & Last Name*

Camper's Preferred Name (optional)

Camper's Birthdate*

Date

What will your camper's age be on their first day of camp

Gender*

MaleFemale

Mailing Address*

City*

State*

Zip Code*

Email Address*

example@example.com

Parent/Guardian #1 First & Last Name*

Parent/Guardian #1 Cell Number*

Parent/Guardian #2 First & Last Name*

Parent/Guardian #2 Cell Number

Additional Contact Name (optional)

Additional Contact Cell Number (optional)

Food Allergies or Dietary Restrictions*

Drug Allergies*

All Other Allergies*

List all medications they take daily.*

List any physical or health related limitations.*

List any concerns you would like for the nurse and staff to be made aware of?

Date of last Tetanus shot.*

Family Physician*

Family Physician Phone*

Insurance Company*

Group Policy#*

Is preauthorization required?

YesNo

If yes, what limits?

Mississippi Church of God MSCOG Youth Camp

Dear Parent/Legal Guardian: The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. As a result, federal, state, and local governments and agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. We are doing everything we can to be compliant with all regulations and ensure your safety. We have put into place preventive measures to reduce the spread of COVID-19, but we cannot guarantee that you or your family members will not become infected with COVID-19.

By participating in programs, services, and activities of our organization, you agree to the following: On behalf of yourself and your children, you hereby release, covenant not to sue, discharge, and hold harmless Mississippi Church of God, it's employees, agents, and representatives, of and from all liabilities, claims, actions damages, costs, or expenses of any kind arising out of or relating to your participation in our programs, services or activities. You understand and agree that this release includes any claims based on the actions, omissions, negligence of this organizations, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any hosted or programmed event by this organization.

Parent/Guardian Printed Name*

Medical Policies

In keeping with the policy of many schools and child-care facilities, every camper will be checked for head lice before they are allowed to check-in their dorm. This process will be handled discreetly and professionally. However, anyone with head lice or nits will not be admitted to camp.

All medications will be collected at camp registration and will be administered only by the camp nurse. This includes over the counter medications. Prescriptions should be clearly labeled (send only the exact amount needed for the time at camp).

Any camper that develops a fever over 100.4 will be sent home.

In the event a camper becomes sick, it is sole responsibility of the Parent/Guardian to pick up their child from camp.

General Rules

Weapons of any kind including, but not limited to, guns, knives, explosives or fireworks, are not permitted.

The use of or posession of tobacco, vapes, drugs (this includes perscriptions not given to the camp nurse), or alcohol is not permitted

Public displays of affection between campers are not permitted.

Rough horse play, pranks, gossip, vulgar language, fighting-physically or verbally, bullying, will not be tolerated.

It is recommended that campers not bring expensive items such as -jewelry, clothing, electronics, or excessive amounts of money.

Dress Code

Modest dress and conduct becoming a Christian witness is mandatory. We maintain a high standard.

Clothing with vulgar or inappropriate words or images will not be permitted.

Tank tops, halter tops, short skirts, short shorts, short shirts, are not permitted.

Athletic shorts are acceptable, but we request that they not be rolled up and they should cover as much as possible.

Every day play clothes that can get dirty for daily activities are suggested. It is not necessary to purchase new clothing.

One piece swim suits and modest 2 piece "Tankini's" are acceptable.

Campers will be required to wear shirts, shorts, and shoes while walking to and from the pool.

Campers will need a pair of athletic shoes that can get muddy or wet for daily attivities, flip flops for the pool, & shoes they can wear to church.

We recommend casual Wednesday night church attire for worship services.

Visitors Policy

In case of an emergency, please call the camp office at 601/372-2714.

For the protection of all campers, all visitors must schedule visits with the Youth Director & Camp Coordinator. Family visitors may cause homesickness for the campers...Use wisdom! Visitors are not permitted to stay overnight, but are welcome to attend the evening worship services. Visitors will be asked to leave the grounds at the dismissal of the evening worship service.

Damages to personal and camp property

Any damage to our facilities caused by horseplay and/or pranks will be accessed and a replacement fee for the damage will be required.

We are not responsible for any personal items lost or damaged. Lost items will be held in safe keeping for thirty days only! Afterwards, they will be disposed of. Regrettably, we cannot mail lost items. Campers should carefully pack their bags and double-check their areas to avoid left items.

By submitting an application to the Mississippi Church of God Camp, each camper aggrees:

1. He/She will abide by all rules and regulations of the camp.

2. The camp is a private church - operated camp and is not a public accommodation.

3. He/She will abide by all the teachings/tenets/practices of Church of God

4. Any violation of rules/regulations may result in the dismissal of camper from the camp, at camper's expense, including transportation home.

5. His/her belongings, including suitcases, backpacks, and all possessions, may be searched at any time by camp administration.

6. Camp administration reserves the right to dismiss any camper for any reason, all in the sole discretion of the camp adminstration.

Parent/Guardian Signature: by signing I understand the MSCOG Camp policy for COVID 19*

Clear

Camper Commitment

I understand that MSCOG Youth Camp maintains a Christian standard for conduct and dress. If accepted, I promise to abide by all rules and policies of the camp and submit to those in authority during my stay.

Camper's Signature: I have read and understand the Camp Rules and Camper Commitment.*

Clear

Camper Printed Name*

Parental Consent

Rules for acceptance to and participation in camp are the same for everyone without regard to race, color, or national origin. I hereby give my child consent to attend and participate in the Mississippi Church of God Youth Camp. This permission includes being photographed during various camp activities, that may be posted to social media. I understand that the camp administration reserves the right to dismiss any camper at any time or refuse any application. I hereby waive, release, and discharge all claims, demands and causes of action against camp officials, the Church of God in Mississippi, the International Offices of the Church of God. All Seasons Worship Center, Camp Cypress. their agents, employees, and participants larising from any damages. property loss or injury my child might sustain at the Mississippi Church of God Youth Camp. In the event of an accident or serious illness, and in the event I cannot be contacted, I hereby consent to allow camp officials to seek and obtain medical or surgical treatment for my child.

Parent/Guardian Signature: I have read and understand the Camp Rules and Parental Consent. I am in agreement with the terms in this application and I consent for my child to attend MSCOG camp.*

Clear

Parent/Guardian Printed Name*

You should receive an email with a copy of your application to the email address entered above. Please review and make sure all information is correct. If changes are needed email ydsec@mscog.org

Payments: You can mail your full payment into our office or call to make a credit card payment. Include your childs name and the camp they are attending with your check.

Mail to:

Attn: Youth Camp

1000 Lake Village Circle

Brandon, MS 39047

Phone number for Credit Card Payments Mondays & Tuesdays:

601-372-2714

For Questions email ydsec@mscog.org

2023 Mississippi Church of God Youth Camp Application

Camp Cost

Camps Choices

Camper Information

Please answer every question to the best of your knowledge. If no answer is available repond with NA.

Camp Rules

Camper Commitment

Parental Consent