Field Camp Application

Application Deadline: Feb 17th 2023

Name: * Email Address: *

First Name Last Name

For approval, ensure email is correct

Date of Birth: * Gender: *

mm-dd-yyyy Female
DOB Male
Non-Binary
Other

University/College of Current Enrollment: * Expected Graduation Date: *

University of Houston mm-dd-yyyy

University you are currently attending.

PeopleSoft ID:

ex: 23
Provide this IF you are a student at University of Houston.

Status (as of Spring 2022): * Major: * Cumulative GPA: *

ex: 23

Your Permanent Address: *

Street Address

Street Address Line 2

Please Select

City State
Zip Code

Your Phone Number *

 -
Area Code Phone Number

Emergency Contact Name: *

Emergency Contact Number: *

 -
Area Code Phone Number

Plan of field camp enrollment: *

Geology Session 1 (6/5 – 7/9/2023)

Geophysics (5/19 – 5/29/2023)

Faculty or academic advisor who can verify your academic information:

Name : * Email: *

faculty_name@university.edu

Attach your Transcript: *

Click to select file

Name it Lastname_Firstname.pdf

Do you have a physical or medical condition that might limit your ability to participate in
the often strenuous physical activities of a field camp? If your answer is “yes”, you must
obtain and submit written permission from your doctor allowing your participation in our
field camp program. *

YES
NO

Student attending field camp are required to carry health insurance for the duration of
field camp. Please provide the name of your insurance provider (If you don't have
insurance and plan to get it by the start of camp, please indicate below) : *

Add Medical Insurance Provider Name

If you have a scanned copy of your medical insurance, please attach:

Choose File No file chosen

By entering my name below, I certify that all entries on this application are complete and
accurate to the best of my knowledge. *

Signature - Enter Full Name