Colorado Back Packin The Rockies 2017
 
Colorado Back Packin The Rockies 2017
CAMPER INFORMATION
Childs Name  * 
Date of Birth  * 
Childs Age  * 
Gender
Home Address  * 
EMERGENCY CONTACT INFORMATION:
Emergency Contact/Parent or Guardian  * 
Emergency Contact Phone Number  * 
Relationship to Child  * 
Secondary Emergency Contact  * 
Secondary Emergency Contact Phone Number  * 
Insurance Information:
Insurance Company Name  * 
Group #
Policy #
Cardholder
Relationship to Child
Information packet will be handed out closer to camp time with releases and consent forms to be signed.
Insurance Company Phone Number
Personal Medical Information:
Physicians Name:
Physicians Phone Number:
Please list physical limitations (Asthma, diabetes, allergies, etc.) and/or special instructions (allergic to certain meds, rare blood type, wears contacts, etc.)
Is your child on any medications? If so, please list medication name and dosage: (must have pharmacy label and Dr's name on it)
Please list all operations/serious injuries and dates within the past 5 years.
Does your child have allergic reactions to bee stings?  * 
Is your child allergic to Poison Ivy, Oak or Sumac?  * 
Can your child swim?  * 
I want to make payment for this camp * total price for the camp is $250.00.  * 
I would like to pay $ 
Your Email Address  * 
Total $
 
 
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