Kent State University Department of Geology

Summer Field Camp Application Form
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Geology

Please complete this form, print it out and return it, along with a non-refundable $50 deposit and the required medical

documentation (see below) by February 28 to:

 

Director, Summer Field Camp

Department of Geology

Kent State University

Kent, Ohio 44242

Please make deposit checks payable to:

Kent State University, Department of Geology

For complete field camp information see:

http://dept.kent.edu/geology/courses/fieldcamp.html

Use this link to access a text version of the Geology website

I. Personal Information

Name: Gender:

 

Academic institution and address:

 

Permanent Address:

E-mail: Phone:   Cell:  

I intend to ride to and from Field Camp in a KSU vehicle:   Dormitory room preference:

II. Academic Information

Intended degree:   Intended major:

 

KSU considers me to be a resident of: (state)   Student Status:

Check courses you will have taken before Summer Field Camp:
Earth Dynamics (Physical Geology) Petrology  Geomorphology
Earth History (Historical Geology) Field Methods Structural Geology
Mineralogy Paleontology Stratigraphy

III. Medical and Health Insurance Information

 

List any allergies, either to natural substances or medication, of which the Field Camp Director should be aware:

 

List all medical problems you have:

INOCULATIONS: All participants must provide written proof of a current tetanus inoculation with the final payments for Field Camp. These shots may be administered by any physician.

Attached is written proof of my tetanus inoculation

Health Insurance Co.: Policy # (required)

 

IV. Emergency Contact Information (Required)

 

Name of emergency contact: Relationship:

 

Address of emergency contact:

 

Emergency Phone:   Emergency Cell:   Emergency email: