Camp Director

Sponsoring Department             Mail Code or Mail Box

Requester's Name                 Requester's Phone

Requester's E-mail

Date of Camp (Beginning)               Camp Ending

Number of Days to be Covered

Covered individuals may not include SIU students, staff or faculty.

Number of Campers to be Covered

List of Campers*

*If more than 25 campers, please fax a list to 618/453-5442 or e-mail Sherri Phillips at sherrip@siu.edu.
This listing must be received no later than the first day of camp.

Number of Counselors to be Covered

List of Counselors to be Covered (if any)

Account Title to be Billed

AIS Number                

Fiscal Officer Name

By submitting this form, you are authorizing University Risk Management to charge the above account for Camper Insurance and you are affirming that all listed individuals are not SIU students, staff, or faculty and that this camp is funded solely by the University.

Please print a copy of your confirmation for your records.