Register for Camp Hickory

Counselor Registration Information

All fields are required. This is the registration form to use if you will be a 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*

MM slash DD slash YYYY

Email*

Club Number*

Club (CHURCH) Name*

Council*

T-Shirt Size*

Adult sizes

2XL

3XL

4XL

Past Camporees Attended

(Hold down CTRL or command button to select multiple options)

Camporee Certificate*

Provided for past Camporee

Will be sent

Counselor Certification date*

MM slash DD slash YYYY

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

Yes - please explain below

Conviction explanation

Consent*

- I have completed the Camporee Certification Course.
- 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 counselor 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 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 videotapes of me to be used by the Calvinist Cadet Corps for promotional purposes.

I have read the Camporee assumption of risk and responsibility statement and agree to the terms stated.

Counselor's Signature*

Signatures

Signing below certifies that the registrant is an active member of our club and has displayed leadership ability, shows by his actions that Jesus Christ is Lord of his 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

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 Phone*

Emergency Contact #1 Mobile 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*

Health History

Special Medical Conditions

Hay fever, asthma, or wheezing

Eczema or frequent skin rashes

Convulsions/Seizures

Heart trouble

Diabetes

Frequent colds, sore throats, ear aches (four or more per year)

Trouble with passing urine or bowel movements

Shortness of breath

Speech problems

Dental problems

High sensitivity to poison ivy

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 7/22/2013

MM slash DD slash YYYY

Has camper received standard childhood vaccines and immunizations?*

Yes

Please explain vaccines/immunizations

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

How will you be paying the registration fee?*

I will pay by credit card using one of the Cadet stores.

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

My club is paying 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