Extreme Camps Mission Trip Insurance

Save my progress and resume later | resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Application sent over a SSL (secure server) A virtual ID card will be emailed to you within 24 hours.
* If you are within a 100 mile radius of Garden Valley, please call 1-800-576-2674 and ask for Craig Robinson.
Cost = $27 (age 30 and under)
Cost = $37 (age 35 thru age 60)
Medical Benefit = $50,000
$0 Deductible

Your Information

Full Name:

Email: *

Phone #:

()

Address

Street Address

Address continued

City

State

Zip

Date of Birth: *

Departure Date: *

Return Date: *

Credit or Debit Information

Card: *

Name on Card: *

Credit Card Number: *

Expiration Date: *

Security Code: *

Please enter the characters you see in this picture:

Characters

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.
Can't see the image? Click here for an audible version in english.

Save my progress and resume later | resume a previously saved form

Short-Term Temporary Medical Insurance Application for Extreme Camp Insurance

Short-Term Temporary Medical Insurance Application for
Extreme Camp Insurance