SAMPLE
INDIVIDUAL INFORMATION
- GSA FIELD TRIP PROGRAM PLEASE MAIL OR EMAIL THIS FORM BY 1 OCTOBER TO: GSA, MEETINGS DEPT., P.O. BOX 9140, BOULDER, CO 80301 mvanotterloo@geosociety.org |
Trip #:_________ Leader: _________________________
Name _________________________________________________________________
Address _______________________________________________________________
Work Phone ____________ Home Phone ___________ Email
___________________
TO ASSIST YOUR LEADER IN PLANNING THE TRIP PROGRAM:
Will this be your first visit to the geographic
area covered by this trip? Yes___ No_____
If no, prior visits occurred in ______________________________________________________________________
Briefly describe your background(s) both professional and other:
______________________________________________________________________
______________________________________________________________________
Please indicate your primary geological interests:
______________________________________________________________________
______________________________________________________________________
TO ASSIST YOUR LEADER IN PLANNING THE TRIP LOGISTICS:
| Sex: | Male ________ | Female ________ |
| Room Requirement: | ________ Double Occupancy (no additional charge) | |
| ________ Single Room (extra cost to be paid direct to hotel) | ||
| ________ Smoking | ________ Non-Smoking | |
If possible, are there other trip participant(s) you would like to room with?
Please supply their name(s).
_______________________________________________________________________
_______________________________________________________________________
Do you have any special dietary requirements? i.e. vegetarian, etc.
_______________________________________________________________________
_______________________________________________________________________
Most trips involve some walking, sometimes strenuous. Are you in good
health? _________
Do you need services to accommodate a disability? Yes __________No __________
If you answer yes, your trip leader will contact you by telephone for further information.
Name of Medical Insurance: _________________________________________________
Insurance Agent: _________________________________________________________
Policy Number: _____________________
In case of emergency during the field trip, please list two people who may be contacted who are not traveling with you.
| Name | Name |
| Address | Address |
| City, State Zip | City, State Zip |
| Telephone Day: | Telephone Day: |
| Telephone Evening: | Telephone Evening: |
