Individual Information Form

Department of Earth and Environmental Sciences

Faculty of Science

For Current Students

Individual Information Form

Name

Address

Phone numbers (cell/home/work):

Email address:

In case of emergency during the field excursion, please list two people who may be contacted who are not traveling with you:

Contact 1

First Name

Last Name

Street Address 1

Street Address 2

City

State / Province

Postal / Zip Code

Country

Telephone (Day)

Telephone (Evening)

Contact 2

First Name

Last Name

Street Address 1

Street Address 2

City

State / Province

Postal / Zip Code

Country

Telephone (Day)

Telephone (Evening)

Excursions may involve some walking, sometimes over rough and uneven terrain and up steep banks. Are you able to fully participate in these types of activities (please check one):

Yes

If no, please provide details below

Declaration of Medical Information and/or accommodation*:
Do you have any special medical requirements or allergies that may or affect your ability to participate in field work activities on this excursion? If so, please provide details on a separate sheet and provide to the course instructors.

If you require regular medical or other support and the use of specific facilities or assistance while at Field School, you are strongly advised to consult with the AV俱乐部 Accommodation Office well in advance of the field school start date with your accommodation request.

* If you have a condition that may put you or others at risk, you may be obligated to share your medical information or any accommodation requirements. Any information you do provide will remain confidential.

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