| II. Applicant Information |
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Name (Last, First, Middle I) |
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Male / Female |
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Permanent Address: |
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Home Phone |
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Cell Phone |
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Email |
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Country of Citizenship |
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Date of Birth (00/00/0000) |
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Place of Birth |
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Passport Number |
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Place of Issue / Date of Issue |
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Name of College/University (if applicable) |
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-Major / Minor (if applicable) |
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Emergency Contact Information |
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Name (First, Last) |
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Address |
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| Home Phone |
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| Work Phone |
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| Cell Phone |
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| Email |
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| Fax (if applicable) |
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| Relationship to you |
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| III. Reference |
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| Please provide one academic or professional reference |
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| Name (Last, First) |
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| Affiliation |
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| Address |
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| Home Phone |
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| Work Phone |
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| Cell Phone |
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| Email |
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| Relationship to you |
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| IV. Statement of Interest |
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| This statement should include a brief description of your interest in this project, and what experience you have had that might be helpful on this project. Please list all educational or professional background that is pertinent. Note, however, that participants need not have any special training or experience. Also, please briefly tell us about any previous foreign travel,which countries you have visited, when and how long. |
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| V. Medical Conditions |
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| Medical treatment will not be equal to the norm in the US. Please be sure to list all special medical conditions you may have. You must bring any prescription or over the counter medications that you require. |
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| Please list any medical condition you have or have had over the last (5) years: |
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| Blood Type |
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| Special Diet or Foods |
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| If your dietary requirements are different than noted in the information provided on the Project Overview associated with this application, you should plan on bringing any required (or desired) foods. |
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| Check any that apply: |
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| Diabetes: |
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| Epilepsy: |
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| Allergies: |
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| Loss of consciousness? |
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| Other (please be specific): |
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| Any health concerns that we should be aware of such as bad back, knee problems etc.? |
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| VI. Conditions |
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I have read the Project Overview, and have read all and/or agree to read all other materials sent
to and received by me about the program for which I am applying, and feel informed.
As a team member (hereafter Participant) of the Khanuy Valley Settlement Project, I will adhere
to the regulations and maintain a standard of good conduct. The director of the expedition
(hereafter Director) reserves the right to require a Participant to withdraw at any time if conduct
or behavior jeopardizes the welfare of any participant or the fulfillment of the objectives of the
project. Additional travel costs due to early dismissal will be the entire responsibility of the
Participant. It is understood that the Participant will assume all responsibilities, financially or
otherwise, for any illness or injury which might occur during the expedition. Emergency
transport, medical or hospitalization costs resulting from illness or accident during the expedition
are the responsibility of the Participant receiving such care. In cases where the Director, in
consultation with the Participant and local medical authorities, considers it necessary, a
Participant will be sent home or hospitalized. The Director will make every effort to ensure that
an ill or injured volunteer receives proper medical attention. The Participant is aware that while
taking part in this project, certain exposure to risks may occur. Exposure may include but not be
limited to: accident and/or sickness without readily available medical facilities, the forces of
nature, travel on the ground and in the air, and others. In consideration of the right for the
Participant to engage in this project, he or she assumes all of the risks involved and agrees to
indemnify and hold the Director of the project and his Associations harmless for any and all
liability that may arise in connection with travel to and from the archeological site, to any of the
excursions, and while engaged in any archaeological or other activities.
I have read and fully understand and accept the conditions for participating in this archaeological
expedition.
I declare that all information provided in this form is true, complete and correct to the
best of my knowledge. |
| By checking this box I agree that this is my "digital signature" |
Digital Signature Required
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