Date:

Family Name:   Date of Birth:

First Name:     Middle Name:

ICCP Number:   (Sample HBIS-345 Regular Program Only)

Name of Camp:

Arrival date in U.S.

I am requesting (1) week of insurance. I understand that if I am going to be here longer that sixteen (16) weeks, it is my responsibility to purchase additional insurance.

I am requesting (2) weeks of insurance. I understand that if I am going to be here longer that sixteen (16) weeks, it is my responsibility to purchase additional insurance.

I am requesting (3) weeks of insurance. I understand that if I am going to be here longer that sixteen (16) weeks, it is my responsibility to purchase additional insurance.

I am requesting (4) weeks of insurance. I understand that if I am going to be here longer that sixteen (16) weeks, it is my responsibility to purchase additional insurance.