Participant Information

* Gender

* Birth Date

Only applies to campers under the age of 18

Contact Information
Additional Contact Information

* Emergency Contact

* Family Physician

* Family Dentist

Riding Home Contact

Only required if the person is different than the custodial parent/guardian.

Insurance Information

* Are you covered by insurance?

Health Information

Describe CAUSE, REACTION and TREATMENT for items such as but not limited to poison Ivy/Oak, Insect Bites/Stings, Foods, Medications, etc.

Describe any diet restrictions the camper may have.

Describe any past/recent medical treatment or illness.

Medical Conditions

Please indicate if the camper has any of the following medical conditions. Explain any that are marked in the following text area.

* Are immunizations up to date?

Must be within the past 10 years. If over 10 years, please contact a physician.

Camper Medication and Physician Information

You will be contacted when/if:

  • Your child is exposed to a communicable disease
  • Outside medical attention is necessary (e.g. if we transport to doctor’s office/hospital)
  • Your child is having discipline problems that jeopardize the safety of other participants

Medications are the responsibility of the camper unless parent/guardian has communicated with Xtreme camp director to have a cabin counselor responsible for dispensing. (We do not have a camp nurse to dispense medications)

Restrictions could be physical, mental, or emotional that would prevent the camper from participating in certain activities.

Camp Authorization

The camper listed above has permission to attend Xtreme Camp from July 25 - 30, 2010 at Hidden Acres Camp in Dayton, Iowa. This permission is given with full knowledge of the conditions and activities contemplated. The participant has no physical or mental disabilities that would impair their participation except as noted above. I/We will not hold the camp ground or Xtreme staff liable for injuries suffered as a result of the camper’s own voluntary actions.

In the event of medical emergency (illness or injury), I/we authorize the physician to undertake such treatment of and perform such services (including surgical) for the participant as are reasonably indicated by the circumstances.

I understand that the camp insurance is an accident policy, not a medical illness policy, and is a supplemental policy only.

I give permission for my child’s image, photograph, or other reproduction to be taken without reimbursement for the sole purpose of promotional pieces.

If there is any change in my youth's medical condition between now and the camp, I will provide updated information to the xtreme camp staff.

The participant is currently taking only medications listed above. The camper has no allergies known to me/us except as noted on this form. The health information/history is correct as far as I/we know. If there is a change between now and camp, I will provide updated info to the Xtreme camp staff.

I have read and understand the above information and will cooperate with camp staff. I understand that registration fees are not refundable.

Do you agree to these terms?