MARINE BIOLOGY RESEARCH CAMP
PARENT APPLICATION
(TO USE THIS, SIMPLY PRINT, FILL OUT AND MAIL IN)
CAMP DATE REQUESTED:_____________________
NAME_____________________________________________________________________________________
ADDRESS__________________________CITY_________________________STATE_________ZIP_________
AGE_______DATE OF BIRTH___/___/___SS#____________________________MALE______FEMALE______
HEIGHT_______WEIGHT________T-SHIRT SIZE MED______LG______XL______XXL_____
PASSPORT #_____________________EXP DATE_________APPLYING FOR PASSPORT AT THIS TIME____
NOTE: A VALID PASSPORT IS NECESSARY TO TRAVEL TO
HONDURAS.
YOU MAY OBTAIN A PASSPORT FROM ANY CLERK OF COURTS OFFICE.
SCHOOL
NAME________________________________________________________GRADE_____________
ADDRESS__________________________CITY_________________________STATE_________ZIP_________
TELEPHONE( )____-_________NAME OF BIOLOGY
TEACHER__________________________________
PARENT/GUARDIAN INFORMATION
NAME_____________________________________________________________________________________
ADDRESS__________________________CITY_________________________STATE_________ZIP_________
DAYTIME PHONE( )____-_________EVENING PHONE(
)____-_________
FAX #( )____-________
ATTENTION_____________________E-MAIL_______________________
DEPOSIT ENCLOSED________@$300.00/STUDENT = $___________CHECK #_________MONEY
ORDER_________
VISA/MC_______AMEX_______DISC________ACCT. NUMBER_________________________EXP
DATE_______
SIGNATURE_________________________________________DATE_________________
ARE YOU INTERESTED IN SELLING T-SHIRTS AS FUND RAISER?________CALL FOR MORE
INFORMATION
DIVING HISTORY:
ARE YOU CERTIFIED?__________IF YES, WHAT AGENCY___________LEVEL___________
IF NO, ARE YOU INTERESTED IN A VIDEO HOME STUDY OURSE?____________CALL FOR MORE
INFORMATION
NUMBER OF LOGGED DIVES__________DO YOU NEED TO RENT EQUIPMENT?______________
MARINE BIOLOGY RESEARCH CAMP • 210 DENIER DRIVE • LAFAYETTE, LA • 70508 • 1-888-477-MBRC
MEDICAL HISTORY
CHECK THE APPROPRIATE BLANK IF YOU HAVE EVER HAD ANY OF THE FOLLOWING APPLY TO YOU, AND EXPLAIN UNDER REMARKS, INDICATING THE NUMBER.
| ___1. ELECTROCARDIOGRAM ___2. MENTAL OR EMOTIONAL PROBLEMS ___3. OPERATION OR ILLNESS ___4. HOSPITALIZED ___5. SERIOUS INJURY ___6. PHYSICAL HANDICAP ___7. REGULAR MEDICATION ___8. ALLERGIES, INCLUDING DRUGS ___9. FREQUENT COLDS OR SORE THROAT ___10. SEVERE OR FREQUENT HEADACHES ___11. REJECTED FROM ANY ACTIVITY FOR MEDICAL REASONS |
___12. HAY FEVER ___13. SINUS TROUBLE ___14. MOTION SICKNESS ___15. CLAUSTROPHOBIA ___16. CONTACT LENSES ___17. EAR OR HEARING PROBLEMS ___18. ALCOHOL PROBLEMS ___19. DENTAL PLATES ___20. TROUBLE EQUALIZING PRESSURE ___21. DIZZINESS OR FAINTING ___22. HEART TROUBLE |
___23. ASTHMA ___24. TUBERCULOSIS ___25. RESPIRATORY PROBLEMS ___26. PERSISTENT COUGH ___27. DIABETES ___28. CHEST PAIN ___29. MEDICATION ___30. BRONCHITIS ___31. HIGH BLOOD PRESSURE ___32. ANY MEDICAL PROBLEM NOT LISTED |
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REMARKS________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
MEDICAL INSURANCE COMPANY__________________________________________________________________________
PHONE #_____________________________POLICY #________________________________________________
POLICY HOLDER_________________________________________________________________________________________
OTHER INFORMATION____________________________________________________________________________________
______________________________________________________________________________________________________
PLEASE ATTACH A PHOTOGRAPH OF APPLICANT FOR IDENTIFICATION
MEDICAL TREATMENT RELEASE
I DO HEREBY AUTHORIZE GREG HIDALGO OF DIVERS DESTINATION OR HIS REPRESENTATIVE, TO SECURE MEDICAL TREATMENT FOR MY SON/DAUGHTER, _______________________________, IN THE EVENT OF AN EMERGENCY.
MOTHER______________________________
FATHER______________________________
GUARDIAN____________________________