Last Name *

First Name *

email *

Your preference for date(s) of Ecuador expedition in 2010. Check both if you would like to attend both terms. (Mexico applications are not yet being accepted)*

Phone *

Street Address *

Street Address (continued)

City *

State/Province *

Zip/Postal Code *

Country *

Passport Number (if available)

Personal Web Site (if applicable)

Are you 18 years of age or older?

  Yes No No but will be by time of expedition.

Are you currently enrolled
in a college or university?

  Yes No

Your current or last college or university

If currently enrolled,
what is your class rank?

  N/A Freshman Sophomore Junior Senior Master’s Student Doctoral Student

What is your highest
degree earned to date? *

  None High School Associate’s Bachelor’s Master’s PhD

What is/was your major
or degree or field of study?

What is, or was, your grade-point
average or equivalent statistic?

Are you interested in applying for academic
credit through your college or university?

  Yes No Not Sure

How did you find us?

  Web Search Engine Web Advertisement Email list Public Event Word of mouth Other

Please specify specific source
(website, email list, etc.)

List two Personal References. These should be instructors, professors, colleagues, or work supervisors who are familiar with your work in academic, field or working settings.

Name of first personal reference *

Relationship of first personal reference to applicant *

email of first personal reference *

Affiliation, address and phone number of first personal reference. *

Name of second personal reference *

Relationship of second personal reference to applicant *

email of second personal reference *

Affiliation, address and phone number of second personal reference. *

Personal Statement: In about a page of text, outline what you expect to gain by this program, either professional or personal. Feel free to elaborate on your personal interests and background. Also in this statement, give a brief self-assessment of your own abilities as they might relate to rigorous field work, working in groups, and under primitive conditions.*

Medical Conditions: Please list any physical or mental conditions which may potentially interfere with your abilities to work in a rigorous field setting. These may include, but are not limited to, chronic injuries, severe allergies, asthma, diabetes, physical handicaps, or learning disabilities. We have a rigorous anti-discrimination policy, and will make every effort for reasonable accommodations for those with any medical conditions or disabilities. It is important that you be very thorough in your answer. *

List any food allergies or meal preferences. Vegetarian meals are often available, although fish is common in meals at some locations, and a fish-only diet is always available. *

Emergency Contacts: List two people, such as a parent or spouse,
each having a separate phone number.

Name of first emergency contact *

Relationship of first emergency contact to applicant *

First emergency contact email, phone, and postal address *

Name of second emergency contact *

Relationship of second emergency contact to applicant *

Second emergency contact email, phone, and postal address *

Resume or CV (optional)

Color Scanned Copy of Passport (if available)

legal waiver

Any other information or comments
not covered in this application.

I am 18 years of age or older, and I have read the entire description of the trip content provided on the web site ReptilesAndAmphibians.org and have given all information herein truthfully and to the best of my knowledge. *

Date *

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