Camper & Counselor Application 2026

Is this application for a Camper or Counselor?*

CamperCounselor

Does the camper have 2 places of residence?*

NoYes

Parent/Guardian - Contact Information
Parent/Guardian #1
First Last*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Parent/Guardian #2
First Last*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.

Medical Release Information
Does the applicant have health insurance?*

YesNo
Insurance Information
Name of Health Insurance
Policy Number
Provider
Primary Physician Name*
Primary Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Physician Phone*
Format: (000) 000-0000.
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Is the applicant presently being treated for an injury or sickness, or taking any form of medication for any reason?*

NoYes
Is the applicant allergic to any type of food or medication?*

NoYes
Does the applicant require a special diet?*

NoYes
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

In case of medical emergency contact:*

Rows	Name	Phone #	Relationship to Child
Contact #1
Contact #2
Contact #3

I understand that I will be notified in the case of a medical emergency involving the applicant. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event the applicant is injured or becomes ill.
Parent's/Guardian's Initials*
Applicant's Signature*
I understand that Southeastern Mississippi Youth Outreach Ministries, Inc. is not responsible for any medical expenses incurred, and that all such expenses shall be the responsibility of the individual signing below.
Parent's/Guardian's Initials*
Applicant's Signature*

We ask that the parents/guardians, campers, and workers read and agree to comply with the attached list of rules for the camp. These rules may be amended and will be enforced. Those not complying will be dealt with as deemed necessary.
SMYC Camp Rules & Dress Code

Camp Rules

• Campers must obey all counselors.

• No boys in girls’ dorms and no girls in boys’ dorms.

• No tobacco, vaping, or related products are allowed on camp premises.

• No cell phones, MP3 players, iPods, iPads, or similar devices.

• Campers may not leave camp without permission.

• No firearms, knives, or fireworks are allowed.

• No clothing that promotes secular music, alcohol, or immoral messages.

• No body piercings are allowed except for females, who may wear one small stud earring per ear. No other piercings (including nose rings, tongue rings, etc.) are permitted. All other jewelry is subject to the discretion of camp leadership.

• All unregistered persons must leave at curfew and may return at the next service time.

• All campers must attend all services and activities.

• Campers may not leave camp alone or with other campers.

• No food is allowed in dorms.

• Counselors are responsible for keeping dorms clean, including taking out trash.

• If a camper brings a vehicle, it must remain parked unless permission is given.

• Registered campers must stay in assigned dorms unless approved by a pastor, parent, or youth leader.

• Respect others’ personal belongings.

• Violation of rules will result in appropriate disciplinary action.

Dress Code

Females – Activities

Jeans or skirts only. No spandex, jogging pants, wind pants, capris, or shorts. Clothing must not be tight. No holes in jeans or skirts.

Sleeved shirts only. No sleeveless tops, spaghetti straps, tank tops, low-cut tops, or midriff exposure.

Females – Church Services

Dresses or skirts only. Must extend below the knee, even with leggings. No slits above the knee.

No sleeveless tops, spaghetti straps, tank tops, low-cut tops, or midriff exposure. No pants.

Males – Activities

Jeans or wind pants only. No jogging pants or shorts. No holes in jeans. No skinny jeans.

Sleeved shirts only. No sleeveless shirts, tank tops, or midriff exposure.

Males – Church Services

Dress pants and dress shirts are recommended. Jeans are acceptable.

Swimming Dress Code (Males & Females)

Shorts and a dark-colored t-shirt are required. Males and females will swim at separate designated times.
Signature of Applicant:*
Signature of Parent/Guardian:*
For more information or questions concerning this camp, please call Keith Hutcherson 601-410-0689 or Cody Hutcherson 601-735-1092.
Make all checks payable to SMYC Outreach Ministries, Inc.
Should be Empty:

SMYC July 5-10, 2026

Camper & Counselor Application

Parent/Guardian - Contact Information

Parent/Guardian #1

Parent/Guardian #2

Medical Release Information