Register for Camp Hickory

Cadet / Jr. Counselor Registration Information

All fields are required. This is the registration form to use if you will be a cadet or jr. counselor at the 2023 Cadet International Camporee.

"*" indicates required fields

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date of Birth*

Email*

Club Number*

Club (CHURCH) Name*

Council*

T-Shirt Size*

Adult sizes

Past Camporees Attended

Cadet or Junior Counselor

Cadet

Junior Counselor

Camporee Certificate*

Provided for past Camporee

Will be sent

Jr. Counselor Certification date*

Have you ever been convicted of anything other than a minor traffic violation?*

Yes - please explain below

Conviction explanation

Counselor's Signature*

I certify that this registrant is an active member of our club and has successfully completed the Camporee Certification Course, including earning the required merit badges or guide trail.

Counselor Signature Date*

Counselor's Name

Head Counselor's Signature*

Head Counselor Signature Date*

Head Counselor's Name

Skills/Certification

First Aid Certified*

Yes

Assumption of Risk and Responsibility

- The registrant named on this registration form has my permission to attend the 2023 Cadet International Camporee in Michigan. I have read the requirements for camporee attendance and to the best of my knowledge the registrant meets these requirements. - I certify that the information on this form is true to the best of my knowledge. As legal parent or guardian, I understand that every effort will be made to contact me, but do hereby give permission for camporee medical staff or any licensed physician to render emergency medical care to my son in the event of a medical emergency. - I hereby release Dynamic Youth Ministries and the Calvinist Cadet Corps, its agents, employees, volunteers, and other parents from any liability for any claims of damages or injury to my child or my child's property. I understand that by signing this agreement, I absolve the Calvinist Cadet Corps, its agents, employees, volunteers, and other parents for any liability for any claims of damages or injury to my child and my child's property, for any injury or damages that may occur, including serious injury and death. I also covenant and agree not to sue Dynamic Youth Ministries and the Calvinist Cadet Corps, its agents, employees, volunteers, and other parents for any liability or any claims of damages or injury to my child and my child's property. I have read this release and covenant not to sue. I understand it and agree that I am bound by its provisions. - I give permission for photographs or videos of my child to be used by the Calvinist Cadet Corps for promotional purposes.

Parent/Guardian's Signature*

I have read the Cadet Camporee information above and agree to the terms of the assumption of risk and responsibility.

Parent/Guardian Signature Date

Parent/Guardian Name*

Cadet or Jr. Counselor's Signature*

Cadet/Jr. Counselor Signature Date

Family Camping / Sunday Visitors

Number of people camping at family camp who need transportation to the Sunday worship service and lunch:

Not camping, but visiting for Sunday worship and lunch? How many reservations do you need?

Insurance Information

Insurance Company/Plan*

Insurance Policy Number*

Emergency Contact Information

Parent/Guardian Name*

First Last

Parent/Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone*

Parent/Guardian Mobile Phone

Parent/Guardian Email*

Relationship to Camper*

At camp or camping nearby? If so, where?

Emergency Contact #2 Name*

First Last

Emergency Contact #2 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact #2 Phone*

Emergency Contact #2 Mobile Phone

Emergency Contact #2 Email*

Emergency Contact #2 Relationship to Camper*

At camp or camping nearby? If so, where?

Other persons to whom child may be released in an emergency

(Recommend listing adults traveling with the child)

Emergency Release Person 1 Name

Emergency Release Person 1 Relationship to Camper

Emergency Release Person 1 Phone

Emergency Release Person 1 at camp?

Yes

Health History

Special Medical Conditions

Other Medical Conditions*

Things to be watched for, such as fainting, sleepwalking, history of emotional or behavioral disturbance, etc. Please explain.

Special Dietary Requirements*

Dietary needs or restrictions such as gluten, lactose, or nut intolerance, diabetic, etc. Please explain.

Allergic Reactions

Allergies to medications, food, or environmental factors. NOTE: Bring your own EpiPen(s) if required.

Allergy

Reaction

Treatment

EpiPen Req'd

Date of Tetanus Immunization*

REQUIRED - date must be after 7/22/2010

Has camper received standard childhood vaccines and immunizations?*

Yes

Please explain vaccine/immunization

Medications

Please list all. Medications must be in original containers.

Medication

Dosage

Frequency

Currently used?

Activity Restrictions*

because of any illness, injury, or physical disability?

Yes

Degree of Restriction

Please explain the degree of your restriction

Operations or Injuries

Other

List anything else you think should be passed on to the boy's cadre counselor and camporee staff.

FINANCIAL ASSISTANCE

Cornel Rylaarsdam Memorial Fund

Some families would like to send their son to an international camporee, but they simply don’t have the financial resources to make it work. The CRMF is available to help pay part or all of the registration fees for individuals who need help. The request is reviewed by the Steering Committee of the International Camporee.

DOWNLOAD APPLICATION

CONTRIBUTE

Give to the Fund

Your contribution will give boys the opportunity to participate in this great adventure.

DONATE TO THE FUND