Student Name
*
First Name
Last Name
Student Email Address
*
Student Phone Number
*
(###)
###
####
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Phone Number
*
(###)
###
####
Additional Parent/Guardian Email Address
School Student Currently Attends
*
Current Class
*
Freshman
Sophomore
Junior
Senior
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Have you ever participated in a WFSI trip?
*
No
Yes - Summer
Yes - Spring
Please list the high school science courses you have taken or are now taking, and indicate the year taken, semester grades, and teacher
*
Please list any science courses you plan to take before graduating from high school
*
Do you plan to pursue a college education?
*
Yes
No
Unsure
What are your career goals?
*
In what types of physical activities do you regularly participate?
*
Do you consider yourself a strong swimmer?
*
Yes
No
Do you sleepwalk or sleep talk?
*
Yes
No
Do you have any allergies?
*
Yes
No
If you answered "yes" to having allergies, please list them, their severity, and your treatment plan
Why do you want to be part of the WFSI 2023 Northwest Course?
*
What positive contributions will you make to the group?
*
How will you benefit or grow from participating in the trip?
*
This trip includes many hikes in which students will hike several miles at a steep incline with gear. Please explain what you will do in order to prepare yourself for this type of strenuous activity.
*
What will you do to prepare yourself mentally for this trip?
*
Please use this space to give us any additional information you think would be helpful for us to know about you.
Parent Agreement - READ CAREFULLY AND IN ITS ENTIRETY
*
I affirm that I am a parent or legal guardian for the child listed in this application under "Student Name."
I am aware that my child is interested in the Worthington Field Studies program. Likewise, I am aware of the total cost of the program ($2750), with the $150 deposit due upon application and the $750 non-refundable deposit due the night of the first meeting. I am aware that once this deposit is made, if for some reason my child is unable to take part in the Worthington Field Studies Program, all monies which have been paid up to that point in time are forfeited. I am also aware of the possibility that if my child breaks a trip rule, he/she will be sent home at my expense. In such case, I am aware that all fees paid will be forfeited. I am aware that if my child is chosen for the trip and decides to return home during the trip, the costs associated with the return home of the student and an adult chaperone will be paid by me and no monies will be reimbursed.
I affirm that my child will be fully vaccinated (defined as at least two weeks post-second shot for a Pfizer or Moderna vaccine or two weeks post-shot for a Johnson & Johnson vaccine) against the COVID-19 virus prior to June 1, 2023. I understand that I will have to show proof of vaccination as part of the course paperwork. I understand that there are no exceptions to this requirement. I understand that my child still needs to bring face masks and may be required to wear a face mask in accordance with local, state, or federal laws as well as trip leader discretion. I understand that, though all precautions will be taken against COVID-19 and other illness, my child may still contract COVID-19 or other illnesses that require isolation and/or medical attention and that they will be taken to the nearest hospital for treatment.
I affirm that my child has no mental, physical, or medical conditions that would impede their ability to participate in this strenuous outdoor program. I understand that this trip is a Science Class and that NONE of the teachers or staff are mental health professionals.
If a mental health, physical health, or medical health issue arises for my child, I understand that my child will be taken to the nearest hospital and the costs associated with the hospital care and return home of the student and an adult chaperone will be paid by me and no monies will be reimbursed.
I understand that attendance at pre-trip meetings and classes is MANDATORY. I affirm that at least either I or my child, but ideally both, will be in attendance at the monthly pre-trip meetings starting in January 2023. I affirm that my child will have no other obligations and be in attendance for the entire duration of the pre-trip classes on June 14, 15, and 16 and for the clean up day on July 17.
I understand that all paperwork, including a notarized form, is due at the final pre-trip meeting in May.
If my child is not accepted into the Worthington Field Studies program, the $150 application deposit will be refunded.
