Chadwick Enrollment Form • Ceiba Foundation

Personal Information

Name*

First Last

Your Email*

Please confirm your email address

Preferred Name (Optional)

Pronouns (Optional)

Phone*

Please confirm your cell phone number

Passport Number

We require your passport number to make in-country travel arrangements; however, if you do not yet have a passport, please email us the number as soon as you obtain one. Note that your passport must be valid to at least 6 months beyond your date of return.

Date of Birth*

Permanent Mailing Address

Address where you can receive any documents or materials in the weeks leading up to the program.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Diet and Health Information

Please be as complete as possible. Detailed health information allows us to offer you the best possible service at field sites and provide you with appropriate care in the event of a medical emergency.

Please check all items that you WILL eat:*

Chicken
Beef
Pork
Fish
Eggs
Dairy
None (i.e., Vegan)

Please detail below any other dietary restrictions or food allergies you have:*

Please indicate below any specific non-food allergies you have:*

You may use the box below to provide more information on your specific allergies.

Penicillin
Sulfa-based medications
Insect bites or stings
General seasonal allergies
I have no known allergies
Other

Allergy Details

If you indicated any allergies above, please provide a detailed explanation including the types of medications and/or insects or other allergens you are allergic too, and the nature of your reaction.

Medical History*

Please indicate by checking the box if you have had or are presently experiencing any of the following. If none of these conditions apply to you, please check the NONE box.

Medical History Details

If you checked any of the conditions above, please provide a detailed explanation, including how recently you have experienced the condition and what routine treatments you require:

List any prescription drugs you take, other than birth control.*

Enter "none" if you do not take any prescription drugs.

Emergency Contact Information

Please provide complete information about who we should contact in the event you are involved in an emergency situation while in Ecuador.

Name*

First Last

Relationship to you:*

Day Phone*

Night Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Certification and Signature

Vaccination Verification*

I understand that I am required to be fully vaccinated against Covid-19 by an FDA approved vaccine (Pfizer, Moderna, or Johnson&Johnson) to participate in this program. I certify that I am fully vaccinated or will be by the time the program begins.

Electronic Signature*

Please type full name.

Date*

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

Chadwick Galapagos Enrollment Form

Personal Information

Diet and Health Information

Emergency Contact Information

Certification and Signature