FLYC 2025 Registration Form

FLYC 2026 Registration Form

Register as a Volunteer, Counselor, Counselor In Training (CIT), or Camper
LATE NOTICE!

The deadline for submitting Youth Camp applications was May 17, 2019.

While we are still accepting applications, you will be subject to a $25 late fee.

If you have any questions regarding this, please email us at YouthCamp@fortslakeag.org.
Camp Information & Prices

Forts Lake Assembly of God is hosting its annual Youth Camp, Monday–Friday, June 8–12. The 5-day, 4-night camp includes morning and evening services, games, activities, bunks, meals, and a banquet.

Fees:
- Camper (ages 12–18): $110
- Counselor, CIT, or Volunteer: $75 (includes $15 background check fee)
- Late registration (on or after May 18): $25
Speakers:
- Morning: Stephen Taylor
- Evening: Joe Ganze
Notes:
- Only registered participants of camp age may stay in the dorms.
- CIT applicants must be 19, limited to 2 per church, and only the first 20 approved applicants will be accepted. Senior Pastor approval is required.
- Background check fee ($15) applies to all applicants 19+ and is non-refundable.
For more information, see our webpage.
Applicant Information

Enter information about applicant
Full Name*

First NameMiddle NameLast Name
Address*

Street # or PO Box

Street Address

CityState

Zip Code
Primary Phone No.*
Format: (000) 000-0000.
Gender*
Current_Date*

MonthDayYear
Current_Date
Birthdate*

MonthDayYear
Date of Birth
Age
*This will auto-populate
Applicant's Email Address

Confirmation EmailNote: This email address is for providing additional information to campers and/or parents. Your privacy is respected, and your information will not be shared with any other party.
Emergency Contact Name*

First NameMiddle NameLast Name
Emergency Contact No*
Format: (000) 000-0000.
Insurance Policy No.
Name of Medical Insurance Carrier
Insurance Phone Number
Format: (000) 000-0000.
If the applicant is on medication, the medication must be sent in the original container with the correct name and dosage/instructions on the container. Please send only enough medication for the alloted time at the camp.
NOTE: Answering 'No' to any questions on this page will not prohibit the applicant from attending. This is so that we may take precautions should a health issue arise.
YesNo
If Yes, please explain:*
Full Time Camper / Day Camper

Dorm beds are limited and assigned on a first-come, first-served basis. Please select below so we can track available beds.
Staying in dormsStaying in RVStaying at hotel or other facilityDay Camper
Dorm Selection*
If you are staying in an RV at the camp, please be sure to complete the RV Spot Registration Form. There are limited number of 50amp and 30amp spots.

__PRESENT
Church Information

Information about the church that the applicant regularly attends
Church Name*
Pastor's Name*

First NameLast Name
Church Phone Number*
Format: (000) 000-0000.
Role Selection
CamperCounselor / C.I.T. / Staff / Volunteer
Counselor (age 20+)Counselor In Training [C.I.T.] (age 19)Kitchen/DiningNurseMaintenanceTech Booth (Audio / Camera / Live Stream / ProPresenter)Point of Sale MachinesOther
Parental / Guardian Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone*
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Parent/Guardian Email Address

Confirmation EmailNote: The purpose of this email address is to provide additional information if needed to the camper and/or parent(s). We respect your privacy and your information will not be shared with any other party or group.
Release Statement: Parent or Legal Guardian
I give permission for my child to attend camp and participate in all activities (unless noted). I confirm the health information is accurate and authorize staff to provide first aid for minor issues and, in an emergency when I cannot be reached, to seek medical treatment as recommended by a physician. I also allow staff to inspect my child’s belongings and remove any prohibited items.

I release Forts Lake Assembly of God, Inc. and its staff from liability for injuries or damages arising from participation in camp activities and accept the associated risks. I confirm my child is physically able to participate.

I grant permission for the use of my child’s photos or recordings for camp purposes. I acknowledge that we have read the Camper Handbook, and my child may be dismissed without refund for failing to follow its policies.
Parent / Legal Guardian eSignature*
By typing your name above, you agree to sign this form electronically, with the same legal effect as a handwritten signature.
Date*

MonthDayYear
Date
Staff Questionnaire
YesNo
YesNo
YesNo
If Yes, please explain.*
YesNo
If Yes, please explain.*
YesNo
Statement: Staff / Counselor / Volunteer
In consideration of participating in activities at Forts Lake Assembly of God, Inc., I release the organization and its staff from all liability for any injury, loss, or damage, including those resulting from negligence, and assume all associated risks. I certify that I am physically and mentally able to participate.

This release is intended to be as broad as permitted by Mississippi law and remains in effect until revoked in writing.

I confirm that I have read the Counselor Handbook, Policies, and Procedures and understand my responsibilities.
Counselor eSignature*
By typing your name above, you agree to sign this form electronically, with the same legal effect as a handwritten signature.
Date*

MonthDayYear
Date
Background Check
For insurance purposes, all counselors are required to complete a background check.

After submitting this form, you will see a link to complete and submit the background check.
Payment
All payments are expected at time of Registration. Acceptable payment methods are Cash, Check, or Credit/Debit Card. All checks should be made out to Forts Lake Youth Camp.
Should be Empty:

FLYC 2026 Registration Form

Camp Information & Prices

Applicant Information

Full Time Camper / Day Camper

Church Information

Role Selection

Parental / Guardian Information

Release Statement: Parent or Legal Guardian

Staff Questionnaire

Statement: Staff / Counselor / Volunteer

Background Check

Payment