Cooperative Leadership Camp Registration
Cooperative Leadership Camp is a full week overnight camp for High School students from across our state. Teens from all parts of the state are sponsored to attend for free by their local cooperative. We can take between 50-70 teens for the program for optimal success. The program is an experiential learning processes where the teens build a worker/owner tee shirt cooperative, elect a board, hire a general manager, design and produce tee shirts. They learn about the leadership, governance, and the 7 cooperative business principles during the entire process. The teams put together the 7 Principles Infomercials to perform, have a leadership awards banquet night and learn what it means to be a part of the greater good that cooperatives offer. The week also contains workshops from other cooperative industries including the agriculture sector, credit unions, retail and utilities. The objectives are to educate, connect and promote the cooperative way of doing business and provide a fun learning experience for the teens that are selected to attend.

2018 Dates are June 18-22 at the FFA Center in White Lake, NC.

Have you been selected to be sponsored by a Cooperative? *
Please check each required item: *
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Full name (First, M.I., Last): *
Your answer
Preferred Name:
Your answer
Full Mailing Address: *
Your answer
Age at Camp: *
Your answer
Date of Birth: *
Your answer
Home Phone:
Your answer
Cell Phone: *
Your answer
Parent Email:
Your answer
Camper Email: *
Your answer
School: *
Your answer
School Contact Email Address: *
Your answer
Current Grade Level: *
Your answer
Year of Graduation: *
Your answer
Sponsor Coop: (Sponsor is an organization member of the CCNC and will sponsor and pay for the student to attend.)
Your answer
Do you want to ride the bus to and from White Lake, NC? *
Choose your bus stop location:
Will you be driving yourself to camp or getting a ride?
Tee Shirt Size: *
Consent and Release: I grant the Cooperative Council of NC the right to use and/ or distribute photographs, films and videotapes of my child for promotional use. I understand that pictures from the Cooperative Leadership Camp are used to promote its Youth Programs via newspaper, website, brochures and newsletter. hat pictures from the Cooperative Leadership Camp are used to promote its Youth Programs via newspaper, website, brochures and newsletter. I give my consent to the Cooperative Council of NC to use such items for promotional purposes only, including press releases to local newspapers on awards my child may receive at camp.
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Parent/ Guardian Signature: *
Your answer
Camper Signature: *
Your answer
Custody Release: The following is for your child’s safety. Please understand that all campers must checkout with a Counselor before departing camp. You may be asked to produce a photo ID at check-out if you are picking up your child. If camper is carpooling, please list name of person driving that vehicle. I give permission for my child to be allowed to leave Co-op Camp and the FFA Center at the conclusion of the camp program into the custody of (name)_______________________. If it is necessary for my child to leave before the end of the camp program due to illness, injury or behavioral issues, and I cannot be reached, I hereby give permission for my child to be released into the custody of (adult name) ____________________ who can be reached at (phone) _______________________.
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Name: *
Your answer
Adult Name: *
Your answer
Phone: *
Your answer
Parent Signature: *
Your answer
Camper Signature: *
Your answer
Code of Conduct: It is understood that the student will exhibit good conduct at all times and will abide by camp rules, which will be given to campers before arrival and at camp orientation. Major infractions of rules will constitute cause to notify parent/ guardian and possible dismissal from camp. If dismissal because of conduct, parent will be required to pick student up from camp during the same day.
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Parent/ Guardian 1 Name and Cell Phone: *
Your answer
Parent/ Guardin 2 Name and Cell Phone: *
Your answer
Other Emergency Contact Name and Cell Phone:
Your answer
Student's Physician and Phone Number: *
Your answer
Student's Insurance Company and Policy Number: *
Your answer
Please list any physical conditions or medical requirements that should be considered in rendering medical treatment:
Your answer
Please list any medications that the student takes regularly and will have at camp:
Your answer
Please list any allergies:
Your answer
Please check: *
Required
I, the undersigned, do hereby give permission for my son/ daughter to be taken to a physician or medical facility, recommended by the Cooperative Council of NC, should he/ she require medical attention during the Cooperative Leadership Camp at the NC FFA Center at White Lake, North Carolina. I further give permission to competent medical personnel to administer such medical treatment and/ or hospital care as needed including medications, injections, anesthesia, surgery and other proper treatments for my child as named above and that necessary information be released for insurance purposes.
Your answer
Parent/ Guardian Signature: *
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Date: *
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Full Address: *
Your answer
Cell Numbers: *
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Local Newspaper: *
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Newspaper Phone: *
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Newspaper Email: *
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Please list and describe any school or community activities: (clubs, offices held, sports, church, service activities, etc.)
Your answer
Honors and Special Achievements:
Your answer
Hobbies, Talents and Interests:
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Do you currently work?
If yes, where and what position?
Your answer
Educational and Career Plans for the Future:
Your answer
Other Information:
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Signature: *
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**Note - Once all paperwork for registration received by CCNC, a confirmation mailing will be sent out as well as further camper information for CLC. We are happy to answer any questions or concerns prior to CLC by contacting our offices at 919-834-5544.
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