Geology Field Experience / Participation Approval Form - Health Services

Geology Field Experience / Participation Approval Form

Date*
Clearance Process*
- I have read and understand the processes and requirements for participating in the field experience.
Student Name*
First Last
This acts as your legal and binding signature and indicates that all of the information provided is factual to the best of your knowledge.
Student ID / T#*
Student Email Address*
Course Number*
Instructor Name*
Instructor's email address*
Do you have asthma or have you ever experienced an induced asthma attack?*
- Yes
- No
Do you have any known allergies to food, plants, insect stings or bites?*
- Yes
- No
Do you take any medications on a regular basis?*
- Yes
- No
Do you have any other condition(s) that might compromise your ability to participate in field activities?*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.