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Tropical Ecosystem: Andes to Amazon

Enrollment Form

Enrollment Deadline:  April 11

Congratulations on your acceptance to this summer's tropical ecology field course in Ecuador!  We are pleased to have your participation in this exciting learning adventure!

As indicated in your acceptance letter, there are a few things we need to complete your enrollment.

1.  Fill out the Enrollment Questionnaire online, or download it to print, fill out, and mail.
2.  Mail your original signed release form.
3.  Mail your tuition payment along with the above forms by above deadline
4.  Submit your Travel Itinerary by June 1.
5.  Read the FAQ about traveling to Ecuador

Send your tuition payment and forms to:

Ceiba Foundation for Tropical Conservation
Education Program
2319 North Cleveland
Chicago, IL 60614 U.S.A.
Fax:  (773) 871-3798

 

Online Enrollment Questionnaire

Download this form

Contact Information

Name:

Email:

Passport Number:

Date of Birth (mm/dd/yyyy):    /  /

Current Mailing Address

Address Line 1:

Address Line 2:

City: State:     Zip or Postal Code:

Country:

Phone:       Fax:

Diet and Health Information

Please check all the foods that you WILL eat:

chicken beef pork fish eggs dairy

Please specify any other dietary restrictions:

Please list any allergies you have:

Can you swim?   Yes      No

Are you currently CPR certified?   Yes       No

Please describe any conditions, medical or otherwise, that course staff should know about in the event of an accident or medical emergency:
None

Please any prescription drugs you take:
None

Emergency Contact

Contact name:

Relationship:

Address:

City:

State:      Zip:

Country:

Daytime phone:

Nighttime phone:

Email:

Physician

Name:

Phone:

Medical Insurance Provider

Course participants are required to have a valid insurance policy that provides coverage while engaging in a field education program in a foreign country. Please provide policy information below:

Company: Policy Number:

Address:

Phone: Valid through (mm/dd/yyyy): / /

Submit Enrollment Form
I certify that information provided on this form is true and correct. I understand that I am responsible for any costs associated with medical insurance, assistance or evacuation during the period that I will be a participant in a CFTC field course.

Yes       No

E-Signature (Please type full name):

Date submitted (mm/dd/yyyy):   / /

                     

Click “Submit Form” to send your application by email.  Click “Clear form” to start over. Click the "Back" button in your browser to return from the confirmation message you will see.

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Tuition Payment

The tuition for the 2008 field course is $2,990. Your $50 application fee will deducted from this amount. Please remit the remaining $2,940 to CFTC by check, money order or wire transfer. Note: if you are applying through the University of Wisconsin - Madison's office of International Academic Programs, you will be billed for your tuition remainder.

Make checks payable to Ceiba Foundation.

If we do not receive payment in full by the enrollment deadline, CFTC will assume you do not intend to participate in the course, unless you have contacted us previously to make payment arrangements. For wire transfer details, please contact CFTC.

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Travel Itinerary

We recommend you purchase your ticket to Ecuador as soon as possible so that you get the best available fare and seat.  Your itinerary should be sent to us no later than July 1. Since we use this information to schedule your airport pickup, you must notify CFTC of any changes to this itinerary prior to your departure. See the FAQ that was sent with your acceptance letter for more details on arriving in Ecuador.

Download this form

Name:

Email:

Travel to Quito

Date (mm/dd)	Airline	Flight #	Depart Time	Depart City	Arrive Time	Arrive City

Travel from Quito

Date (mm/dd)	Airline	Flight #	Depart Time	Depart City	Arrive Time	Arrive City

                     

If you have any questions, please email CFTC

Ceiba Foundation for Tropical Conservation
Education Program
2319 North Cleveland
Chicago, IL 60614 U.S.A.
Fax:  (773) 871-3798