(confidential: for the instructors' eyes only)

Personal Information: Name: Class: ...............Major: Email: ...............Phone number: U.S. citizen? Yes No If not, give country Courses taken relevant to ecology/marine biology/environmental science/plant biology (including Spring 2004): Please include the course name, term taken, and grade. Other relevant experiences, e.g., field research in ecology/marine/plant biology Relevant skills, Proficiency level: Swimming: can't swim OK swimmer swim like a fish Diving (SCUBA) (not required): not certified certified but seldom dive experienced Hiking: couch potato enjoy a walk ran the marathon Camping: never slept out-of-doors camped a few times when young I can fry an egg on a paper plate Medical concerns (please be honest--your life may depend on it!) We do require that you have a current tetanus/diphtheria shot and that you take an anti-malarial drug (e.g., Chloroquine) while in Belize and Costa Rica. Are you allergic to insect stings? Yes No Have you ever been stung by an insect? Yes No Phobias (irrational fear of insects, snakes, spiders, etc.)? Yes No If yes, please specify: Drugs required periodically? Yes No If yes, what are they required for, are they available overseas, and do they require refrigeration? Do you have any other medical problems? Yes No If yes, please specify:

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