VSU MAYMESTER FIELD BIOLOGY PROGRAM IN RUSSIA

May 10 – June 1, 2000

Application Form

Application fee rec'd.____________

Name__________________________________________________________________________________________________

Last Name, First Name & Middle Name

Current Mailing Address __________________________________________________________________________________

apartment and/or street number city state zip code

Permanent Address ____________________________________________________________________________________

apartment and/or street number city state zip code

(mailings will be sent to this address after May 15, 2000)

Phone Numbers:

area code + current # ____________________________________

area code + permanent # __________________________________

Age________ Birth date ______/______/_______ Social Security #___________________________

Male _______ Female _______ Smoker______ Non-smoker _______

Medical Information: (list chronic conditions, allergies or other special health concerns and prescription medications that you need)

I am in good physical condition and am able to hike, climb, camp, and spend time outdoors without difficulty _____ yes _____ no

Emergency_Contact:____________________________________________________________________(Name)

_________________________ (Phone Number)

_______________________________________________________________________(Street Number, City and State, Zip Code)

Country of Citizenship ______________________________________

_____I am applying for a passport

_____I have a current passport: _______________ __________________ ________________ ________________

Number Place of Issue Date of Issue Date of Expiry

Name exactly as printed in passport: ___________________________________________________________________

NOTE: YOU MUST SUBMIT YOUR PASSPORT TO VSU’S OFFICE OF INTERNATIONAL PROGRAMS BY MARCH 15, 2000 OR YOU WILL NOT BE ABLE TO PARTICIPATE IN THE PROGRAM

College/university currently attending_________________________________________

Classification_________________________________ GPA _______________________

(Fr, Soph, Jr, Sr, Graduate)

Major or area of academic interest ___________________________________________

I acknowledge that participation in a study abroad program involves some risk of injury, illness, or loss of personal property. I agree to release and forever discharge Valdosta State University and the Board of Regents of the University System of Georgia, its members individually, and its officers, agents, and employees, from any and all claims, demands, rights, and causes of action of whatever kind or nature, arising from and by reas on of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, including death, damages to property and the consequences thereof, resulting from my participation in the Maymester 2000 Field Biology Program in Russia and related activities.

I hereby agree to maintain accident and health insurance in force and effect for the entire duration of my participation in the study abroad program. I further certify that, to the best of my knowledge, I am in good health and physicall y capable of undertaking an intensive program of foreign study; any medical or health-related problems have been explicitly described in this application.

I further agree that I shall be subject to the supervision and authority of the faculty in charge and to standards of conduct stipulated by the faculty in charge. I further acknowledge that the supervising faculty or program director ha s sole authority to make decisions regarding the continued participation of any individual in the program whose conduct may necessitate disciplinary action. I further authorize the supervising faculty or program director to obtain and provide medical trea tment and/or services that I may require during the study abroad program.

Finally, I am aware that the deadlines for submission of this application is March 1, 2000, and I agree to abide by the deadlines for fee payment as follows: March 1, 2000-- $150 application fee; March 15-- down payment of $1100; April 1, 2000-- final payment of $1025. I further acknowledge and accept the schedule for refunds, should I withdraw from the program, and accept the penalties associated with late withdrawal, as follows:

Note: All withdrawals must be made in writing to the Office of International Programs at Valdosta State University in order for refunds to be processed.

___________________________________________________________ ________________

Signature of Applicant Date

In case of injuries, I hereby authorize and give consent to the program leaders to obtain and provide medical treatment and services for my son or daughter as deemed necessary.

___________________________________________________________ ________________

Signature of Parent or Guardian Date