*If paying a deposit your card will automatically be charged on June 11th, 2021 for the remaining balance of your registration.  Deposits are non-refundable due to the limited camper capacity.




Key Information

  • I consent to a background check and need a follow up form to fill out.

  • I already have a check per my AG Credentials.





Emergency Contact Information


Release Forms

I assume full liability of hazard and risk for myself (or my child) during the summer camp. I give permission for hospital or medical center staff to administer any necessary treatment immediately to me (or my child) should I (or he/she) be sick or injured during the Festival. I do not hold the district youth ministries nor its respective officers and staff responsible for any injury as a result of my (or my child’s) participation in the camp.

GENERAL RELEASE AND ASSUMPTION OF RISK: KNOWING THE RISKS DESCRIBED ABOVE, WE BEING THE PARENTS/LEGALGUARDIANS OF CHILD PARTICIPANT AGREE, TO ASSUME ALL THE RISKS AND RE-SPONSIBILITIES, KNOWN AND UNKNOWN, SURROUNDING CHILD’S PARTICIPATION IN THE ACTIVITY. TO THE MAXIMUM EXTENT ALLOWED BY LAW, WE RE-LEASE, HOLD HARMLESS, AND AGREE TO INDEMNIFY MISSISSIPPI ASSEMBLIES OF GOD CAMP, ALABAMA ASSEMBLIES OF GOD CAMP, THE MISSISSIPPI DISTRICT OF THE ASSEMBLIES OF GOD, AND THEIR OFFICERS, DIRECTORS, EMPLOYEES, VOLUNTEERS, AND THE ALABAMA DISTRICT ASSEMBLIES OF GOD AND AGENTS FROM AND AGAINST ANY PRE-SENT OR FUTURE CLAIMS, LOSSES, LIABILITIES, COSTS, AND EXPENSES FOR INJURY TO PERSON OR PROPERTY, OR FOR ANY OTHER DAMAGE, WHICH WE OR PARTICIPANT MAY SUFFER, OR FOR WHICH WE OR PARTICIPANT MAY BE LIABLE TO ANY OTHER PERSON, RELATED TO THE PARTICIPANT’S PARTICIPATING IN THE ACTIVITY ( INCLUDING PERIODS IN TRANSIT TO OR FROM DESTINATIONS), RESULTING FROM ANY CAUSE, INCLUDING BUT NOT LIMITED TO NEGLIGENCE ON PARTICIPANTS PART OR ON THE PART OF ANY OF THE RELEASED PARTIES; PROVIDED THAT THIS RELEASE OF LIABILITY SHALL NOT APPLY TO GROSS NEGLI-GENCE OR WILLFUL OR WANTON MISCONDUCT. We hereby warrant that we have read this Agreement carefully, understand its terms and conditions, acknowledge that we are giving up substantial legal rights by signing it, we acknowledge we have signed this Agreement freely and voluntarily, without any inducement, assurance or guarantee. This Agreement represents the complete and entire under-standing between the parties regarding these issues and no oral representations, statements or inducements have been made apart form this Agreement. If any provision of this Agreement is held to be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this Agreement and shall not affect the validity and enforceability of any remaining provisions. We expressly waive any defense to the enforcement of any provision of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms. We expressly agree that this assumption of risk, release, and indemnity Agreement is intended to be as broad and inclusive as permitted by law. I further state that WE HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS, AND WE VOLUNTARILY SIGN THIS AGREEMENT AS OUR OWN FREE ACT. We understand and agree that no oral or written representations can or will alter the contents of this document. We agree that this Agreement shall be governed by the laws of the State of Mississippi, which shall be the forum for any lawsuits filed under or incident to this Agreement or the above described activities. A photocopy or facsimile of this authorization shall be as valid as the original.

PHOTOGRAPH & VIDEO RELEASE: We, Participant’s parents and/or legal guardians, hereby grant Mississippi Assemblies of God Summer Camp, Alabama Assemblies of God Summer Camp, the Mississippi District of The Assemblies of God, and The Alabama District of The Assemblies of God, permission to the rights of Participant’s image, likeness, and sound of Participant’s voice as recorded on audio or video tape without payment or any other con-sideration. We understand that Participant’s image may be edited, copied, exhibited, published or distributed and we hereby waive the right to inspect or approve the finished prod-uct wherein Participant’s likeness appears. Additionally, we waive any right to royalties or other compensation arising or related to the use of Participant’s image or recording. We agree that Mississippi Assemblies of God Youth Convention and Fine Arts, and The Mississippi District of the Assemblies of God may use such images of Participant with or without Participant’s name and for any lawful purpose, including for such purposes as publicity, illustration, advertising, and web content. We understand there is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be used and/or distributed. We, the parents and/or legal guardian acknowledge that we have completely read and fully understand this release and agree to be bound thereby. It is our express intention to defend, indemnify and hold harmless Mississippi Assemblies of God Youth Convention and Fine Arts, and the Mississippi District of the Assemblies of God from any and all claims arising out of Participant’s image, likeness, sound.

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 in place preventative measures to reduce the spread of COVID-19, but we cannot guarantee that you or family members will not become infected with COVID-19.

By participating in programs, services, and activities of The MYC & Mississippi District of The Assemblies of God, and Alabama District of The Assemblies of God, you agree to the following:

On behalf of yourself and your children, you hereby release, covenant not to sue, discharge, and hold harmless The MYC & Mississippi District of The Assemblies of God, and Alabama District of The Assemblies of God, its 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, or negligence of this organization, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any such program, service or activity.


Health History & Medical Treatment Authorization


  • If an inhaler is necessary please comment below.

  • If an Epi Pen is necessary please comment below.

  • If an Epi Pen is necessary please comment below.

  • If an Epi Pen is necessary please comment below.

  • If an Epi Pen is necessary please comment below.





Physician & Insurance Information

  • Please list provider and policy number below.

  • Insurance is required for all Participants attending camp. If you do not have current health insurance - it will be provided to you for the camp week for $25 per person.


$0.00
$0.00

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