APPLICATION FORM

XMO West Coast

June 18, 2017 - June 25, 2017
Newbury Park, California

Application Deadline May 18, 2017

Camp MiVodin

June 25 - July 2, 2017
Hayden Lake, Idaho

Application Deadline May 24, 2017

XMO Rockies

TBD
Rockies, Colorado

Application Deadline Coming Soon

PERSONAL INFORMATION

EMERGENCY CONTACT INFORMATION

PERSONAL INFORMATION

Please Check All That Apply

HISTORY

  • Allergies
  • Asthma
    • Mild
    • Severe
  • Bleeding Disorders
  • Brain Injury
  • Cardiac Limitations
  • Cerebral Palsy
  • Diabetes
  • Epilepsy
  • Hearing Impaired
  • Neurological
    • Concussion
    • Head Trauma
  • Seizures
  • Shunt

OTHER

MOBILITY

  • Independent
  • Cane
  • Guide Dog

DEVELOPMENTAL

  • Mild
  • Moderate
  • Severe/Profound
  • Autism
  • Down Syndrome

BEHAVIOR DISORDER

  • Acting Out
  • Aggressive
  • Self-Abusive
  • Other (Explain)

EMOTIONAL

  • Anti-Social
  • Depression
  • Eating Disorder
  • Substance Abuse
  • Suicidal

INSURANCE