APPLICATION FORM FOR GO350/GO650

Name
SSN

Please provide the following contact information where you can be reached prior to Field Camp:

Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
E-mail

The following is requested for housing assignments:

Age
Sex	Male  Female

Housing in Utah is single occupancy with two students sharing a bath. You may request a person by name with which you would like to share in the space below. Call for details on housing in Cape Girardeau.

Check here to indicate that you are aware that any health expenses you incur during this course are your own responsibility.

Do you have any physical limitations which may adversely affect your field work? (Problems with desert climates, altitudes to 10,000 feet, full work weeks with evening assignments, etc.)

Yes No

If yes, please explain. (We need to know in general if you have special needs that we can accommodate.)

List the geology courses you have had and your grades in each course:

If you have not had a field methods course, please explain why you believe you are ready for GO350 Geology Field Camp. (See required competencies for GO350 enrollment.)

Provide contact information for the person(s) to be contacted in the event of an emergency: