Scholastica Field Studies Enrollment Application

Select Program*

Student First Name*

Student Last Name*

Student Nickname (optional)

Student Mobile Phone*

Email:*

Gender

Female
Male

Student Birthday (MM/DD/YY)*

School Name

Grade (completed by trip start)

Is there any history of the following medical conditions that may effect or preclude participation? Select all that apply.

None
Diabetes
Seizures
Heart Conditions
Severe Allergic Reactions
Gastrological disease
Orthopedic Disorders
Psychological Disorders
Other

If boxes other than \"None\" were selected, please provide detail:

Is there any history of asthma or respiratory problems?

Yes
No

Primary contact for student*

First Name*

Last Name*

Occupation*

Mailing Address*

Mailing Address 2

City*

State*

Zip / Postal code*

Country*

Primary Email*

Primary Phone*

Second Phone

I have read and agree to the Terms of Agreement, including payment methods and payment due dates.*

I understand that my enrollment is not confirmed until Scholastica Travel Inc. has received a $350 deposit by check.*

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