2011 LSU FRESHMAN FIELD CAMP APPLICATION FORM Louisiana State University, State of Louisiana Department of Geology and Geophysics, E-235 Howe-Russell, LSU, Baton Rouge, LA 70803 Applicants to Freshman Field Camp can either be newly admitted to LSU or current LSU students. If you have not been admitted to LSU, please apply online through the LSU website (lsu.edu). Priority for admission is given to Geology and Petroleum Engineering majors. Name ________________________________________________________ Gender:
F
M
Date of Birth_______________
LSU ID # _______________________ Nation of Citizenship _______________________________________________________ Mailing Address:___________________________________________________________________________________________ _________________________________________________________________________________________________________ E-mail Address: _____________________________________________
Phone: _________________________________
Name, e-mail address, and telephone number of Parent or Legal Guardian (minors only)
High School Information (fill out only if you have not previously attended college) High School Attended________________________________________________________________________________ Name, Parish (County), and State Cumulative Grade Point Average:
Date of Graduation:
College/University Information Please provide information for all higher educational institutions attended (if applicable), including LSU. Name Major Dates of Credits Earned Cumulative GPA Attendance
List all courses (not listed on the transcript(s) you provide) you will have completed by May 2011.
Why are you interested in attending the LSU Freshman Geology Field Camp?
Degree Attained
Describe your plans for college studies and the career plans to follow.
List activities, organizations, leadership roles, honors, awards, community involvement, etc. in which you have participated or are currently participating. Include non-athletic competitions you have entered such as Science Fairs, Parish/County Fairs, and State Fairs.
Please attach copies of academic transcript(s) and a copy of your ACT/SAT score report (if available). Please provide the names and contact information (telephone or e-mail) for three persons who have agreed to serve as references for you. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Reference letters are strongly recommended, but not required. I have read and understand this application form. All of the information provided on this form is complete and correct.
Applicant Signature _____________________________________________________________, Date _________________
Parent or Guardian Signature (for minors)_____________________________________________, Date _________________ The information provided is used only as a basis for course admission and departmental financial aid/scholarship awards. It is otherwise held in confidence unless the applicant requests its release in writing. Mail completed and signed application by April 15, 2011 to: Ms. Heather Lee Dept. of Geology & Geophysics E-235 Howe-Russell Louisiana State University Baton Rouge, LA 70803
General Physical Examination Name:
Date of Birth:
Sex:
Height:
Blood Pressure:
Health History
Weight:
/
Yes
Pulse:
No
Satisfactory Yes No
1. Chronic/Recurrent Illness?
Physical Evaluation Comments
2. Hospitallization? 3. Surgery other than tonsils?
VITALS
4. Injuries treated by Physician? 5. Current Medications?
HEAD
6. Organs Missing? 7. Heat Exhaustion/Stroke? 8. Dizziness, Fainting, Convulsions, and/or Headaches?
NECK EYES
9. Knocked Out? 10. Concussion?
ENT
11. Wear Glasses or Contacts? 12. Hearing Defects? 13. Dental Appliances: Bridge/Brace/Cap/Plate?
DENTAL CHEST
14. Cough/Chest Pain? 15. Problems with Blood Pressure, Heart,
HEART
or Murmers? 16. Any sudden deaths before age 50, in
ABDOMEN
immediate family? 17. Problems with Liver, Spleen, Kidneys?
GENITALIA
18. Hernia? 19. Recurrent Skin Disease? 20. Bone/Joint injury? Sprain/Dislocation?
SKIN ALLERGY
21. Allergy to Medications? Name:______________________ 22. Tetanus Booster in the last 10 years? Year__________________
SUMMARY OF COMMENTS:
Item #:
Description:
23. Recent TB skin test? Date_______Results__________
Physician:________________________________________ Date:___________________
Reccommended Follow‐up