You may fill out this form, print it and then FAX it to 303-860-5680 ** This is a Required Field

CAMP INSURANCE REQUEST FORM

NAME OF CAMP ** CAMPUS **: Boulder Denver UCCS

BEGINNING DATE ** ENDING DATE ** TOTAL # OF DAYS ** EXPECTED # OF PARTICIPANTS **

DO CAMPERS SPEND THE NIGHT? ** Yes    No, back to their own house.    TYPE: Academic Sport ACTIVITY ** LOCATION **

DEPARTMENT NAME ** DEPARTMENT COORDINATOR ** CAMPUS BOX # **

MODE OF TRAVEL ** SPEED TYPE NUMBER (Approving Org. #, CO Springs only) **

CAMPUS TELEPHONE ** FAX ** EMAIL ADDRESS **

ADDITIONAL COMMENTS

** This is a Required Field