Intent to Enroll in the 2008
Summer Geology Field Course
NAME:
_____________________________________________________________________
SOCIAL SECURITY
NUMBER: (Optional now but will need
later) __________________
UNIVERSITY (Current
or Last Enrolled)
GEOLOGY COURSES
COMPLETED (Please indicate year taken for those listed)
(Note that the
courses in boldface red are required. If you have not had one or more of these
courses, you should consult with Dr. Harper, the Field Course Director, before
enrolling the course)
______ Physical
Geology ______ Historical
Geology ______ Mineralogy
______ General Petrology (Igneous, Metamorphic, & Sedimentary)
______ Structural Geology ______ Field Methods
(This course is often combined with Structural
Geology)
______ Geomorphology ______ Stratigraphy
(This course is often combined with Sedimentology)
GRADUATION: Are you planning to graduate at the end of
the summer? _________
TRANSPORTATION: The cost of the Field Course includes
transportation by van from several locations along the I-40 Corridor in
______ Departmental
Vans
______ Private
Vehicle
______ Will you be
traveling with the departmental vehicles in your private vehicle?
______ Airline
(Please check with Dr. Harper, the Field Course Director before making
your
airline reservations)
______ Other Modes of
Transportation
______ Don’t know yet (Please notify
Dr. Harper as soon as you know)
MAILING ADDRESS:
PHONE NUMBER (S):
EMAIL:
PERSON(S) TO CONTACT IN CASE OF EMERGENCY WITH PHONE NO.
HEALTH: Do you have any health conditions (e.g.,
allergies, conditions requiring
medication, etc), which might affect your performance during the Geology Field
Course?
______ NO ______ YES (Specify)
_________________________________________
____________________________________________________________
Please list
your health-medical insurance provider and policy number.
Provider
Name __________________________________________________________
Policy Number
__________________________________________________________
ALL STUDENTS MUST CARRY HEALTH-MEDICAL INSURANCE FOR THE
ENTIRE DURATION OF THE FIELD COURSE (May 12-June 25, 2008)
DIET: Do you have any special dietary requirements
(e.g., food allergies, vegetarian, etc)
______ NO ______ YES (Specify)
_________________________________________
____________________________________________________________
Phone(s) where you
can be reached between May 1 and May 11:
Please submit this “Intent
to Enroll in the 2008 North Carolina Summer Geology Field Course” by post or by
email submission to Dr. Harper by March 31, 2008. My contact information is noted below
Dr. Stephen B. Harper
Field Course Director
North Carolina Geology Field Course
Department of Geological Sciences