2024 HYC Counselor Form

We are excited to welcome you back to Eagle Rock this year!

Counselor registration is $100 and will remain open through Sunday, May 19th. No registrations will be accepted after this date.

Minimum counselor requirements:

-At least 18 years old

-Member in good standing in an ICOC church

-Recommendation from local church leader

Name

This address will receive a confirmation email

Phone

Address

Counselor Registration $100.00

Birthdate

Gender

Male Female

T-Shirt Size

Home Church

I am a:

Do you have a child attending camp?

Yes No

Regarding cabin preferences: We will do our best to match counselors up with desired cabins, however we cannot guarantee cabin preference requests.

If you have one or more preferences for your cabin, please select them here: Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelth

Additional comments about cabin preferences (Order of preference, etc.)

EMERGENCY CONTACT Name

EMERGENCY CONTACT Relation

EMERGENCY CONTACT Phone Number

Doctor's Name and Phone Number

Medical Insurance Provider and Policy Number

Year of last TETANUS shot

Do you have any allergies or medical conditions? (Drugs, Food, Environmental)

Yes No

If yes, please list and explain in detail:

Will you need to take medication while at camp?

Yes No

If yes, please provide name(s) of medication(s) and dosage:

MEDICATION POLICY: All medications, including OTC medications, may only be administered by the camp nurse. I agree to deliver all medications in a zip-lock bag, in their original packaging.

I understand and agree.

Regarding dietary requests: Regarding dietary requests: The camp will provide meal options each day to accommodate the following common dietary restrictions:
--Vegetarian
--Gluten Free

If you have unique dietary needs in addition to what is listed above, please provide that information below. A member of the camp staff will reach out to you to discuss.

If you have unique dietary needs (beyond the four listed above), please provide that information here:

Do you have any special physical, mental, or emotional needs?

Yes No

If yes, please provide details:

Would you like a pre-camp call from the camp director or medical personnel regarding your needs? (If you check yes, we will send you a separate form to collect additional details.)

Yes No

COUNSELOR WAIVER: In the event of an accident or injury, I agree not to hold the Heartland ICOC churches or Heartland Youth Camps, or Eagle Rock Retreat Center responsible for medical or recovery expenses related to said injury.

I understand and agree.

TRANSPORTATION WAIVER: I agree not to hold the Heartland ICOC churches, Heartland Youth Camps, or Eagle Rock Retreat Center responsible for any accidents or injuries that may occur in the process of commuting to and from camp.

I understand and agree.

SCREENING POLICY: I understand that applying to be a counselor does not guarantee acceptance. All counselor applications will be reviewed by camp directors. Background screenings will also be run on all counselors. A full refund will be provided if the application is refused for any reason.

I understand and agree.

REFUND POLICY: I am now completing my registration. I understand that if my application is accepted, registrations are non-refundable and non-transferrable.

I understand and agree.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2024 HYC Counselor Form

Description

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