First Name: Last Name:

Email Address:

Phone Number:

Address: City: State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Gender: Male Female

Are you over 18? Yes No

If under age 18, enter a parent or guardian name

What grade are you going into? Select a Grade 6th Grade 7th Grade 8th Grade Highschool Freshman (9th) Highschool Sophmore (10th) Highschool Junior (11th) Highschool Senior (12th) College

Primary Contact: Phone Number:

Secondary Contact: Phone Number:

I have read the camp information and will cooperate with the camp staff. I understand that registration fees are not refundable. In case of medical emergency, I hereby give permission to the physician selected by the staff and/or medical consultant staff at Hidden Acres Campgrounds to secure proper treatment standard with all accepted medical procedures. I give permission for photographs of my child to be used for promotional purposes. My child has permission to leave the Hidden Acres Campground if xtreme camp has a trip as part of it’s program. 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. My youth will be responsible for medications, unless otherwise directed by parent/guardian and the xtreme camp director. (We do not have a camp nurse to dispense medications, but we can direct the camper’s cabin counselor to dispense as directed.) Do you agree to these terms?