2011 LSU GEOL 3666 SUMMER FIELD CAMP APPLICATION FORM Louisiana State University, State of Louisiana Department of Geology and Geophysics, E-235 Howe-Russell, Baton Rouge, LA 70803 INSTRUCTIONS: 1. Respond to all questions. 2. You may fill out electronically, or print out and fill in manually. The information provided by you on this form is used for communication purposes and must be legible if filled out manually. 3. Application to the LSU Geology Field Camp, 2011 session must include an original copy of a basic Physical Exam completed and signed by a licensed, practicing physician (D.O. or M.D.), after February 01, 2011. (The LSU Geology website provides this formNOTE: No prescription forms from doctor will be accepted) The physical report may be sent separately from this and other application documents. 4. Non-LSU students must submit an online LSU undergraduate application for summer enrollment. Please note that applying through LSU Undergraduate Admissions is a completely separate process and does not include anything sent to the Department of Geology and vice versa. 5.Non-LSU students must submit transcripts to the Field Camp Student Coordinator at the address listed at the end of this application. These are solely for the Department of Geology and will NOT be forwarded to Undergraduate Admissions! 6. Mail all application materials to Field Camp Student Coordinator at the address listed at the end of this application. The deadline for scholarship applications and LSU priority admission is March 15, 2011. DO NOT mail any of these materials to any LSU office other than the address below.
Name ________________________________________________ Gender: F Student ID # (LSU), if non-LSU leave blank_________________
M
DOB_______________
Nation of Citizenship _________________
Mailing Address: ___________________________________________________________________________ _________________________________________________________________________________________ E-mail(s)_______________________________________ Phone Number University or College where you are enrolled: ____________________________________________________ Your Classification (e.g., Junior, Senior):_______ GPA at end of previous semester: All courses ___________ Geology courses ___________ Geology courses completed by the beginning of Field Camp (end of Spring semester, 2011): Please provide your Final Grade or Midterm Grade for Spring 2011 courses in the blank. LSU Course Number, Description of Course GEOL 1001 Physical Geology
____
GEOL 2061 Paleontology
____
GEOL 1003 Historical Geology ____
GEOL 3032 Sedimentology
____
GEOL 1601 Physical Geol. Lab ____
GEOL 3041 IG/MET Petrology ____
GEOL 1602 Historical Geol. Lab ____
GEOL 3071 Structural Geology ____
Other geology courses:__________________ ________________________________________________ ______________________________________________________________________________________
Have you ever been charged with criminal conduct under Federal law or under laws or ordinances within any of the following states: Louisiana, Texas, New Mexico, Colorado, Wyoming, Utah, or Arizona? Or, do you have any arrest warrants outstanding in any of these states? No
Yes
(If ‘Yes’, explain the nature and present status of the case):
Have you ever served, or are you now serving in a branch of the U.S. Military?
No
Yes
If ‘yes’, list branch, rank, years of service, and (expected) date of discharge. ________________________________________________________________________________________ Have you thoroughly reviewed the contents of the LSU Field Camp web pages? http://www.geol.lsu.edu/fieldcamp.html ,
No
Yes
Do you have a medical condition or impairment that requires special accommodation as specified in the Americans with Disabilities Act? No
Yes
(Describe the disability and accommodations required)
PLEASE BE AWARE THAT THE APPLICATION PROCESS FOR UNDERGRADUATE ADMISSIONS IS A COMPLETELY SEPARATE PROCESS. IF YOU ARE NOT A CURRENT LSU STUDENT, YOU MUST SUBMIT WHAT THE GEOLOGY DEPARTMENT REQUIRES IN ADDITION TO SUPPLYING THE UNDERGRADUATE ADMISSIONS’ REQUIREMENTS. NOTE: Disabilities requiring special accommodation must be filed by the applicant with the LSU Office of Disabilities Services as part of the application process. All information provided in my application is complete and correct. I understand that false or incomplete information will nullify this application or result in dismissal from the course. Applicant Signature ___________________________________________________, Date _________________ Mail completed and signed information by March 15, 2011 to: Ms. Heather Lee Department of Geology & Geophysics E235 Howe-Russell Louisiana State University Baton Rouge, LA 70803 Checklist for application documents: LSU students: ___ application (required) ___ physical exam report (required) ___scholarship application (optional)
Non-LSU students ___ application (required) ___ physical exam report (required) ___ official transcripts (required) online application to LSU undergrad admissions (required) scholarship application (optional)
College of Science Department of Geology & Geophysics Field Camp
General Physical Examination Name:
Date of Birth:
Sex:
Height:
Weight:
Blood Pressure:
/
Pulse:
Health History
Yes
Satisfactory Physical Evaluation Yes No Comments
No
1.Chronic/Recurrent Illness?
VVI
2. Hospitalization?
VITALS
3. Surgery other than tonsels? 4. Injuries treated by Physician? 5. Current Medications?
HEAD
6. Organs Missing? 7. Heart Exhaustion/Stroke?
NECK
8. Dizziness, Fainting, Convulsions, and/or Headaches? 9. Knocked Out?
EYES
10. Concussion? 11. Wear Glasses or Contacts?
ENT
12. Hearing Defects? 13. Dental Appliances: Bridge/Brace/Cap/Plate? 14. Cough/Chest Pain?
DENTAL
15. Problems with Blood Pressure, Heart or Murmers? 16. Any sudden deaths before age 50, in immediate family? 17. Problems with Liver, Spleen or Kidneys? 18. Hernia?
CHEST HEART ABDOMEN
19. Recurrent Skin Disease? 20. Bone/Joint Injury? Sprain/Dislocation? 21. Allergy to Medications? Name: . 22. Tetanus Booster in the last 10 yrs? Year . 23. Recent TB Skin Test? Date: . Results: .
GENITALIA SKIN ALLERGY
Summary of Comments: Cleared without restriction Cleared with Restriction
Restriction explanation:
Not cleared
Reason:
Physician: Phone number: (
Item #:
Description:
Date: )
Email:
E235 Howe-Russell • Baton Rouge, LA • 70803 • P 225-578-3353 • F 225-578-2302
Recommended Follow‐up