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Study Abroad
▸
Tropical Conservation Semester
▸
Expeditions
▸
Academics
▸
Scholarships
▸
For Parents
▸
Summer Courses
▸
Coral Reef Ecology
▸
Water for Life
▸
Conservation Internships
▸
Get Involved
▸
Internships
▸
Volunteer
▸
Job Openings
▸
EduTour Adventures
▸
Reservation Form
▸
Conservation
▸
Coastal Dry Forest
▸
Lalo Loor Dry Forest Reserve
▸
Reserva Lalo Loor (ESP)
▸
Coastal Conservation Corridor
▸
Cloud Forest
▸
El Pahuma Orchid Reserve
▸
Reserva El Pahuma (ESP)
▸
Mining in Cloud Forests
▸
Amazon Rainforest
▸
Tiputini Biodiversity Station
▸
Community
▸
Environmental Education
▸
Sustainable Livelihoods
▸
Humanitarian Assistance
▸
Research
▸
Current Research
▸
Biological Station
▸
Publications & Documents
▸
Research Application
▸
About Us
▸
Proyectos
▸
Who We Are
▸
Where We Work
▸
Blog Posts
▸
The Ceiba Tree
▸
Kapok – Annual Newsletters
▸
Contact Us
▸
Donate
▸
Donar (ESP)
▸
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Chadwick Galapagos Enrollment Form
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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.
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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
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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.
Asthma
Bleeding Disorder
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Colitis or Inflammatory Bowel Disease
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Heart Disease
Hernia
High Blood Pressure
Joint Injury / Surgery
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Neck / Back Pain / Injury
Rheumatic Fever
Tuberculosis
Ulcer
NONE of these conditions apply to me
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.
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*
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Algeria
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Argentina
Armenia
Aruba
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Austria
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Bahamas
Bahrain
Bangladesh
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Belgium
Belize
Benin
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
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Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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.
Yes
No
Electronic Signature
*
Please type full name.
Date
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Email
This field is for validation purposes and should be left unchanged.