Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Roatan, Honduras: Caribbean Marine Biology - Spring 2008
Participant Information- please print clearly. Application deadline: October 31, 2007
Name:
Gender: M / F Univ. ID#:
Local address:
street
city/state/Zip
street
city/state/Zip
/
E-mail:
Permanent address:
Birthdate:
/
Academic status: fr / so / jr / sr / vet. med. / grad
GPA (cum):
GPA (major):
Major:
Phone: (
)
Phone: (
)
ISU College:
Expected graduation date: ____
Do you currently have a disciplinary charge through the Judicial Affairs Office? _____________
yes/no
Have you ever had a disciplinary charge? ___________
When? _________________________
yes/no
Please explain ________________________________________________________________________
The Study Abroad Center may check your disciplinary status at any time, and this may affect your
enrollment in a program.
List international experience/s, including country, purpose (study, travel, etc.), and length of
stay (can use back of page if necessary).
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
1
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Your application must contain the following in the order listed below.
Submit by October 31, 5:00 PM in room 503 Science II.
_____ Participant Information
_____ A typed one page (or more) essay describing how this trip fits into your educational plans and how
you can contribute to the success of this field trip. We want to know how in the past, and how on
this trip, you can contribute leadership as well as companionship to your fellow travelers. Tell us
what is unique about you and how it will benefit the group experience. This is very important and
will be carefully considered. Decisions based on reading the essay often determines who goes, or
who does not go, on a trip.
______A copy of your resume' listing activities and professional experience
_____ Transcript or copy of recent Fall 2007 degree audit
_____ Signed Conditions of Participation
_____ Signed Waiver of Liability and Hold Harmless Agreement
_____ Signed Waiver of Liability and Hold Harmless Agreement (Aquatic activities)
_____ Aquatic activities information sheet
_____ PHOTOCOPY ALL OF THE ABOVE and submit 1 photocopy with the original
_____ Arrange for 2 letters of recommendation to be sent to trip leader directly (D. Sakaguchi, 503
Science II, dssakagu@iastate.edu; FAX 515-294-8457). Give names with phone numbers/email of those
providing letters of reference. At least one of these references should related with your academics.
1.
Phone/email:
2.
Phone/email:
If accepted as a participant into this Program, you will be required to submit the following information
before final acceptance into this Program (forms will be provided):
_____ Medical History / Health Insurance Verification
_____ Emergency Information / Emergency Medical Treatment
_____ Financial Agreement
These must be submitted in 503 Science II by November 27, 2007, the Tuesday after Thanksgiving. If
your forms are not submitted by this date, your place on the trip may be offered to one of the alternates.
I certify that, to the best of my knowledge, the information in this application is correct.
Signature
Date
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
2
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Conditions of Participation
All applicants are asked to review and sign the following statement that constitutes conditions for participation in all
Iowa State University study abroad programs.
1. I understand and agree that, as a participant in an Iowa State University study abroad program, I am subject to
the following: a) the ISU Student Conduct Code (ISU Student Disciplinary Regulations, Student Information
Handbook), b) the ISU Study Abroad Conduct Code (Study Abroad Student Handbook), c) host institution
conduct codes, and d) host country laws.
2.
I fully understand that the procedures to be used in the event of my violation of any of the respective conduct
regulations are the Study Abroad Disciplinary Procedures contained in the Study Abroad Conduct Code.
3.
I understand that I may be dismissed from the program if a) I engage in actions endangering to others or myself
or b) my conduct is considered to be detrimental to or incompatible with the best interest and welfare of the
program. I further agree, if dismissed from the program, to be responsible for all expenses incurred in returning
to the United States.
4.
I understand that I am subject to the laws of the host country and agree to abide by those laws. I further
understand that Iowa State University may be limited in its ability to provide assistance in the event of my
arrest. ISU may also institute disciplinary proceedings concerning my violation of the laws of the host country.
5.
I am aware of the nature and the cost of the program and will guarantee that all financial obligations will be
met.
6.
I agree that I will not plan any individual travel away from the group or from the facilities hosting our group
during the program.
7.
I understand that Iowa State University reserves the right to cancel programs in the case of insufficient
participation or for other reasons deemed appropriate. Iowa State University also reserves the right to make
changes to the program (such as program leader) or alterations in the program’s proposed schedule and
itinerary. I further understand that should the program, or any portion of the program, be cancelled, Iowa State
University shall have no responsibility beyond the refund of all deposits made and monies paid to Iowa State
University by participants. Minor alterations in the programs will not result in refunds.
8.
I understand that students participating in ISU programs need to be willing to learn about their host cultures and
be open to new ideas even though these may be culturally challenging. I am aware that it is both inappropriate
and culturally insensitive to promote religious or political agendas in a host country; further, such behavior can
cause offense and potentially place me in harm’s way. I understand that I cannot expect to change the society I
am visiting and, as a representative of Iowa State University, I should not engage in such activities. I
understand that freedom of expression is not a universal right and may not be protected by law in some
countries. I will demonstrate a respect for the host culture even though I may not agree with all aspects of that
culture, and I understand that behavior that is inconsistent with this statement may lead to my dismissal from
the program
9.
I understand that I must enroll in, and contribute to the seminar course Biology 394a to be taught in Spring
semester, 2008.
I have read and understand the conditions governing my participation in ISU study abroad programs. I further
understand the possible actions that will be taken should I act in a manner that is inconsistent with these conditions.
Participant’s signature
Date
if under 18 years of age:
Parent/guardian signature
Date
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
3
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Assumption of Risks, Release of Liability, and Hold Harmless Agreement
Name__________________________________________ UID# ________________________
Study Abroad Program _________________________________________________________
PLEASE READ THIS DOCUMENT CAREFULLY. It affects any rights you may have if you are injured or
otherwise suffer damages while voluntarily participating in the above-named study abroad program.
In consideration for my being permitted to participate in this study abroad program, I agree to the following:
1. Assumption of Risks: I understand that there are inherent and unavoidable risks in travel abroad. I assume,
knowingly and voluntarily, the known risks and all other risks that could arise during my travel to, from, in, or
around my site country.
2. Important Websites: I acknowledge that I have been provided with the website addresses for obtaining
information on security, safety, and health for countries to which I plan to travel and that I am responsible for
informing myself of this information. The websites are:
U.S. State Department
www.travel.state.gov
Centers for Disease Control
www.cdc.gov
World Health Organization
www.who.org
3. Orientation: I understand that study abroad orientation is available to me, and I understand that it is my
responsibility to attend.
4. ISU Travel Clinic: I acknowledge that health information, advice, travel preparation, and immunizations are
available to me in the Travel Clinic at the ISU Thielen Student Health Center. I understand that it is my
responsibility to visit the Travel Clinic.
5. RELEASE OF LIABILITY: I acknowledge that I understand that I do hereby, for myself, the members of my
family and spouse if I am alive, and my heirs, assigns, and personal representatives if I am deceased,
RELEASE, WAIVE, FOREVER DISCHARGE, AND COVENANT NOT TO SUE the State of Iowa, Board of
Regents of the State of Iowa, Iowa State University of Science and Technology, and all their officers, faculty, or
employees (hereinafter referred to as “RELEASEES”) whether accompanying the study abroad program or
otherwise, from any and all claims, demands, actions, or causes of action on account of any injury to me or my
property or on account of my death which may occur from any cause during the study abroad program, or any
continuances thereof; and I do hereby expressly covenant and agree to refrain from bringing suit or proceedings
at law or in equity or otherwise as provided by law against any of the RELEASEES on account of any and all
such claims, demands, actions, or causes of action.
6. INDEMNIFICATION: I further AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES
from any loss, liability, damage, or cost, including court costs and attorneys’ fees that they may incur due to my
participation in the study abroad program.
IN SIGNING THIS ASSUMPTION OF RISKS, RELEASE OF LIABILITY, AND HOLD HARMLESS
AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing, understand it, and sign
it voluntarily as my own free will; no oral representations, statements, or inducements apart from the foregoing
written agreement have been made; I am at least eighteen (18) years of age and fully competent (if not eighteen, my
parent(s) or guardian(s) agree with the terms of this document and sign it as such); and I execute this AGREEMENT
for full, adequate, and complete consideration fully intending to be bound by its terms.
Participant signature
Date
Parent/guardian signature if student is under 18
Date
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
4
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Waiver of Liability and Hold Harmless Agreement (for aquatic activities)
AFFIRMATION AND LIABILITY RELEASE
(read carefully before signing)
International Field Trips in Biology: Caribbean Marine Biology Field Trip to Roatan, Honduras
I,
, hereby affirm that I have been well-advised and
thoroughly informed of the inherent hazards of snorkeling, skin diving and scuba diving. By signing this release, I
certify that I am cognizant of that basic risk.
Risk Disclosure: I understand that the following risks are inherent in participating in the above mentioned field trip
(potential risks include, but are not limited to the following): boating accidents, pressure-related injuries, injuries
due to lung overexpansion, decompression illness, squeezes, ear barotrauma, gas-related injuries, nitrogen narcosis,
oxygen toxicity, carbon monoxide poisoning, carbon dioxide toxicity, seasickness, overheating, hypothermia,
sunburn, cramps, near drowning, drowning, injuries from aquatic life, vertigo, carotid sinus syndrome, fish
poisoning, insect bites.
I understand and agree that neither the TRIP LEADERS (Donald Sakaguchi and Dusan Palic) nor
INSTRUCTOR (S) nor the State of Iowa, State Board of Regents, Iowa State University of Science and Technology,
and all their officers, faculty or employees nor the SCUBA SHOP nor the CITY OF AMES PARK AND
RECREATION located in the city of Ames and in the state of Iowa may be held liable in any way for any
occurrence in connection with this International Field Trips in Biology: Marine Biology Field Trip to Roatan,
Honduras or the SCUBA training class which may result in injury, death, or other damages to me or my family,
heirs, or assigns, and in consideration of being allowed to enroll in this Field Trip (and SCUBA training course if
applicable), I hereby personally assume all risks in connection with said Field Trip and training course, for any
harm, injury or damage which may befall me while I am enrolled as a student of the Field Trip and training course,
including all risks connected therewith, whether foreseen or unforeseen; and further to save and hold harmless said
program and persons from any claim by me, or my family, estate, heirs, or assigns, arising out of my enrollment and
participation in this Field Trip and training course.
I further state that I am of lawful age and legally competent to sign this affirmation and release, or that I
have acquired the written consent of a parent or legal guardian; that I understand the terms herein are contractual and
not a mere recital; and that I have signed this document of my own free act. It is my intention by this instrument to
exempt and release the TRIP LEADERS (Donald Sakaguchi and Dusan Palic) and/or INSTRUCTOR (S) and/or
IOWA STATE UNIVERSITY and/or the SCUBA SHOP and/or the CITY OF AMES PARK AND RECREATION
from any liability whatsoever for personal injury, property damage or wrongful death caused by negligence.
I have fully informed myself of the contents of this affirmation and release by reading it before I signed it.
Student Name:
Age:
Date of birth:
(please print legibly)
Student
Address:
Signature of student
Signature of parent or guardian where applicable (if under 18 years of age)
date
date
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
5
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Aquatic Activities Survey for Bio 394: Marine Biology Field Trip
(If you fill-out an application for this field trip, please fill-out this survey.
Note: Being a certified SCUBA diver is not required for this field trip.)
1) Name (print):
2) Campus/local phone:
3) Email:
4) Do you know how to swim?
YES
NO
5) Are you comfortable in open water (i.e. ocean, lake)?
YES
NO
6) Do you know how to snorkel?
YES
NO
If NO, are you interested in learning how to snorkel:
7) Are you a certified SCUBA diver:
YES
NO
If NO, are you interested in enrolling in a SCUBA class:
8) If YES, through which agency are you certified: PADI, NAUI, SSI, Other, etc.
Certifying agency
Date/year of certification
Certification number
9) State when and where was your last open water dive:
10) Approximate number of open water dives you have made:
11) Have you completed any advanced SCUBA courses?
(i.e. Advanced open water, Rescue diver, Divemaster, etc.)
List course/s and agency/s:
12) List locations where you have SCUBA dived before:
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
6
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Study Abroad Reference - Page 1
To be completed by the applicant:
Student Name:
Program for which student is applying: Bio 394 - CARRIBEAN MARINE BIOLOGY: ROATAN, HONDURAS
Reference requested from:
Name (please print)
Title/Position (please print)
Under U.S. federal law (Section 483 of Public law 90-247, as amended), students are permitted access to
certain records. Section 483(a)(2)(B) provides that student may waive the right to inspect confidential
letters of recommendation. Many applicants have found that a recommendation letter written in
confidence has a greater impact than one to which the applicant also has access. If you waive your right
to inspect the information requested by this form, please sign below.
Applicant’s signature
Date
To be completed by the individual providing the reference:
The student named above is applying to participate in Bio 394, an International Field Trip in Biology to Roatan,
Honduras during spring break March, 2008. Your candid appraisal of the student’s propensity for a successful
academic experience and ability to serve as a representative of Iowa State University and the United States is an
important part of the application. The trip will be a demanding, fast pace course, and will require some travel in
remote rural areas. It will involve physical exertion, the ability to manage free time constructively, and a willingness
to contribute to the success of the trip. We are interested in your candid opinion about this student's ability to be a
positive influence on a trip of this nature.
This form can be downloaded as an MS Word document from URL:
http://www.public.iastate.edu/~zoogen/Bio394/Bio394.html
1.
How long and in what capacity have you known the applicant?
2.
Please indicate the applicant’s ability and academic competence in comparison with other individuals whom
you have known at similar stages in their academic careers.
Below Average Above Outstanding Do not
average
average
know
Knowledge in area of
specialization
Motivation and seriousness of
purpose
Ability to plan and carry out
research/independent study
Ability to express thoughts in
speech and writing
Emotional stability and maturity
Self-reliance and independence
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
7
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Study Abroad Reference Page 2
3.
Please comment on the applicant in terms of the following:
a)
Personal suitability for living abroad
b) How participation in an Iowa State University program will be of benefit to the student
c)
Weaknesses of the applicant you are aware of that may adversely impact on the quality of the experience
d) Other factors you believe may affect a successful experience on a study abroad program
4.
Other comments:
Signature of individual providing the reference
Name (please print)
Date
Position or title
Office address, telephone, and e-mail
We appreciate your willingness to take the time to write this letter.
Thank you. Please return by October 31, 2007 to: D. Sakaguchi, Iowa State University, Dept.
GDCB, 503 Science II, Ames, IA 50011 (dssakagu@iastate.edu; FAX: 515-294-8457).
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
8
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Study Abroad Reference - Page 1
To be completed by the applicant:
Student Name:
Program for which student is applying: Bio 394 - CARRIBEAN MARINE BIOLOGY: ROATAN, HONDURAS
Reference requested from:
Name (please print)
Title/Position (please print)
Under U.S. federal law (Section 483 of Public law 90-247, as amended), students are permitted access to
certain records. Section 483(a)(2)(B) provides that student may waive the right to inspect confidential
letters of recommendation. Many applicants have found that a recommendation letter written in
confidence has a greater impact than one to which the applicant also has access. If you waive your right
to inspect the information requested by this form, please sign below.
Applicant’s signature
Date
To be completed by the individual providing the reference:
The student named above is applying to participate in Bio 394, an International Field Trip in Biology to Roatan,
Honduras during spring break March, 2008. Your candid appraisal of the student’s propensity for a successful
academic experience and ability to serve as a representative of Iowa State University and the United States is an
important part of the application. The trip will be a demanding, fast pace course, and will require some travel in
remote rural areas. It will involve physical exertion, the ability to manage free time constructively, and a willingness
to contribute to the success of the trip. We are interested in your candid opinion about this student's ability to be a
positive influence on a trip of this nature.
This form can be downloaded as an MS Word document from URL:
http://www.public.iastate.edu/~zoogen/Bio394/Bio394.html
1.
How long and in what capacity have you known the applicant?
2.
Please indicate the applicant’s ability and academic competence in comparison with other individuals whom
you have known at similar stages in their academic careers.
Below Average Above Outstanding Do not
average
average
know
Knowledge in area of
specialization
Motivation and seriousness of
purpose
Ability to plan and carry out
research/independent study
Ability to express thoughts in
speech and writing
Emotional stability and maturity
Self-reliance and independence
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
9
Iowa State University
INTERNATIONAL FIELD TRIPS IN BIOLOGY APPLICATION
Study Abroad Reference Page 2
5.
Please comment on the applicant in terms of the following:
a)
Personal suitability for living abroad
b) How participation in an Iowa State University program will be of benefit to the student
c)
Weaknesses of the applicant you are aware of that may adversely impact on the quality of the experience
d) Other factors you believe may affect a successful experience on a study abroad program
6.
Other comments:
Signature of individual providing the reference
Name (please print)
Date
Position or title
Office address, telephone, and e-mail
We appreciate your willingness to take the time to write this letter.
Thank you. Please return by October 31, 2007 to: D. Sakaguchi, Iowa State University, Dept.
GDCB, 503 Science II, Ames, IA 50011 (dssakagu@iastate.edu; FAX: 515-294-8457).
DEPARTMENT OF GENETICS, DEVELOPMENT & CELL BIOLOGY, 503 SCIENCE II
IOWA STATE UNIVERSITY, AMES IA 50011
TEL. (515) 294-3112 FAX (515) 294-8457
10