Please fill in the following information:Primary Insurance NameInsurance Name Name of Policy HolderFirst Name Last Name DOBDate Relationship to PatientRelationship Patient's Policy ID No.Policy ID No. Policy Start DateDate Secondary Insurance InformationSecondary Insurance Name (if applicable) Insurance Name Name of Policy HolderFirst Name Last Name DOB Date Relationship to PatientRelationship Patient's Policy ID No.Policy ID No. Policy Start Date Date
Urgent Care and Miscellaneous FeesThe card below will only be used for reimbursements in the following circumstances:- Should my child need to be seen by a physician while on the Camp Extreme program, I understand that I am responsible for all costs and fees. - I acknowledge that all baggage related fees on the flight home from Camp Extreme are at my expense. Signature of Parent or GuardianSignature* Date Visa or MasterCard NumberCC Number* Exp. Date MM/YY* CVV Security Code* Billing Address Street Address* City* State* Zip*
Legal Name of Applicant First Name* Last Name*
- It is the participant's responsibility to arrive at the airport on time and make their flight. Additional flight costs due to late airport arrival will be at the expense of the participant. - Please confirm baggage requirements with your airline and any possible related costs. As you will see from the packing list, a sleeping bag and pillow will be needed. -A valid driver's license or passport is required to fly domestically. It is the participant's responsibility to ensure that they have proper identification.