Chadwick Galapagos Enrollment Form

  • Personal Information

  • Please confirm your email address
  • Please confirm your cell phone 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.
  • Address where you can receive any documents or materials in the weeks leading up to the program.
  • 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.
  • You may use the box below to provide more information on your specific allergies.
  • 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.
  • 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.
  • 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:
  • 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.
  • Certification and Signature

  • 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.
  • Please type full name.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.