counselor signup

Counselor Signup Below!

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Counselor Registration
*Only fill out this form if you are a registered Cadet Counselor.
Name *

First Name Last Name
Birth Date *

Month Day Year
Church/Club *
Club Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Counselor Information
Training & Certification *

Red Cross Standard First Aid Red Cross Basic Water Saftey Red Cross Life Guarding Community First Aid & Saftey Adult CPR Red Cross CPR/Professional None Other
Other Relevant Certification
Previous Experience: Years as Cadet Councilor *
Councilor at Camp *
Current Occupation
Volunteer Positions Needed:
- Obstacle Course assisant
- Rocket Creating assistant
- Compass Course assistant
- Life Guard
- Rifle Range assistant
- Archery Range assistant
Assigned Position at Camp
If not assigned and you wish to help in a certain area or activity, please indicate here.
Secondary area/activity you would be willing to help with
Have you ever been convicted of anything other than a minor traffic violation? *

Yes No
If yes, please explain.
Signature

Clear
Do you have any current litigation of anything other than a minor traffic violation in process at this time? *

Yes No
If yes, please explain.
Emergency Information
Emergency Contact’s Name *

First Name Last Name
Relationship *
Phone Number *
Alt. Phone Number
Is the Counselor prescribed any Medication or Inhaler? If yes, please explain any instructions.
Please list any special needs, limitations, and adaptions for the Counselor.
Informed Consent and Acknowledgement

I hereby give my approval for my participation in any and all activities prepared by Grand Rapids North Council during the selected camp. In exchange for the acceptance my candidacy by Grand Rapids North Council. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Grand Rapids North Council and all its respective officers, agents, and representatives and the Counselors home church and its fellow cadet councilors/club from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to myself, I hereby waive all claims against Grand Rapids North Council including all its respective officers, agents, representatives, coaches and affiliates, all participants, sponsoring agencies, advertisers, Counselors home church and its fellow cadet councilors/club and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, swimming, outdoor activity, and camping. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Counselors Signature *

Clear
Medical Release and Authorization

I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the counselor, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named Counselor. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact your emergency contact in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach your emergency contact.

Permission is also granted to the Grand Rapids North and its affiliates including Directors, Coaches, and and fellow Cadet Councilors to provide the needed emergency treatment prior to the counselors admission to the medical facility.

Release authorized on the dates and/or duration of the registered event.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named counselor.
Counselor Signature *

Clear
Confirmation

BY ACKNOWLEDGING AND SIGNING, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Please verify that you are human *
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1015 Westend Ave. NW
Grand Rapids, MI, 49504
616-453-3077
office@westendcrc.org
*****Sunday Worship Time:*****
9:45am

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Counselor Registration