Register for Camp Hickory

Camp Staff Registration Information

All fields are required. This is the registration form to use if you will be a member of the camp staff at the 2023 Cadet International Camporee.

If you are unable to obtain signatures via this online form, make a mark in the signature fields, and use the separate Staff Signatures Form to obtain signatures and mail to Corps Office.

"*" indicates required fields

Name*

First Last

Address*

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

Phone*

Date of Birth*

MM slash DD slash YYYY

Email*

Club Number*

Use 0000 if you are not a member of a club.

Club (CHURCH) Name*

Council*

T-Shirt Size*

Adult sizes

2XL

3XL

Past Camporees Attended

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

Yes - please explain below

Conviction explanation

Consent*

- I certify that the information on this form is true to the best of my knowledge. I hereby give permission for the camporee medical staff or any licensed physician to render emergency medical care to me in the event of an emergency.
- I am an adult (18+) staff member attending the 2023 Cadet International Camporee. I hereby release Dynamic Youth Ministries and the Calvinist Cadet Corps, its agents, employees, volunteers, and other campers from any liability for any claims of damages or injury to me or my property. I understand that by signing this agreement, I absolve the Calvinist Cadet Corps, its agents, employees, volunteers, and other campers from any liability for any claims of damages or injury to me or my property, for any injuries 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 campers from any liability for any claims of damages or injury to me or my property.
- I give permission for photographs or videotapes of me to be used by the Calvinist Cadet Corps for promotional purposes.

I HAVE READ THIS RELEASE AND COVENANT NOT TO SUE. I UNDERSTAND IT AND AGREE THAT I AM BOUND BY ITS PROVISIONS.

Registrant's Signature*

Signatures

Signing below certifies that the registrant is an active member of our club and has displayed leadership ability, shows by their actions that Jesus Christ is Lord of their life. (Signers must not be relatives to the registrant and no one person may sign more than one category)

Fellow Counselor's Signature*

Fellow Counselor's Name*

Church Council Member's Signature*

Church Council Member's Name*

Cadet Council Board Member's Signature*

Cadet Council Board Member's Name*

(if independent club, second fellow counselor)

Skills/Certification

Do you have skills or certification in any of the following areas?

First Aid Certified*

Yes

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?

Health/Medical Insurance Information

Insurance Company/Plan*

Insurance Policy Number*

Emergency Contact Information

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Address*

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

Emergency Contact #1 Primary Phone*

Emergency Contact #1 Secondary Phone

Emergency Contact #1 Email*

Emergency Contact #1 Relationship to Camper*

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*

Staff Committee

Serving on Committee*

Please check the committee on which you have been asked to serve:

Assistant Camp Director

Adjutant

Registration/Finance

Site

Promotion

Food

Medical

Camp Store

Equipment

Transportation

Chaplain

Program (please specify below)

Program Specifics

Health History

Medical Conditions*

Things to be watched for, such as fainting, sleepwalking, history of emotional or behavioral disturbance, highly sensitive to poison ivy, 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 7/22/2013

MM slash DD slash YYYY

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

How will you pay your registration fee?

I will pay with a credit card through one of the Cadet stores.

I will pay with a check sent to the Cadet Office.

My club or someone else will pay for me.

FINANCIAL ASSISTANCE

Cornel Rylaarsdam Memorial Fund

Some families would like to send their cadet or counselor to an international camporee, but they don’t have the financial resources. The CRMF is available to help pay part or all of the registration fees for individuals who need help. The Steering Committee of the International Camporee reviews requests.

DOWNLOAD APPLICATION

CONTRIBUTE

Give to the Fund

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

DONATE TO THE FUND